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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/intestinalputrefOOpeck 


THE 

INTESTINAL  PUTREFACTIONS 


CLINICAL  STUDIES 


OF 


ENTEROCOLITIS 


BY 

CHARLES  FENNER  PECKHAM,  M.  D. 
PROVIDENCE,  RHODE  ISLAND 


Snow  &  Farnham  Co.,  Printers 
1916 


Copyright,   1916 
By  CHARLES  FENNER  PECKHAM 


All  rights  reserved 


CONTENTS 


CHAPTER  I. 
Enterocolitis. 

The  stages  of  enterocolitis;  the  primary  stage;  the  secondary 
stage;  the  tertiary  stage;  the  three  diagnoses  —  anatomical, 
chemical,  bacteriological;  absence  of  sense  of  pain  in  intestinal 
mucosa;   symptoms  —  local,   general;   the  tertiary  stage. 

CHAPTER  II. 

The  Micro-organisms  of  the  Intestinal  Canal. 

Difficulties  in  their  study;  deductions  from  fecal  and  urinary 
findings ;  classification ;  effects  of  their  growth ;  structural  changes  in 
the  organs;  intestinal  putrefactions;  antisepticus  intestinalis;  putre- 
faction never  present  in  normal  individuals;  conditions  favoring 
the  putrefactive  process;  rate  of  absorption  in  the  intestines; 
bacteria  —  list  of  species;  molds;  cultural  experiments;  list  of 
intestinal  molds;  yeasts. 

CHAPTER  III. 

The  Examination  of  Feces. 

Chemistry;  microscopy;  methods. 

CHAPTER  IV. 

The  Examination  of  Urine. 

The  indices  of  putrefaction;  chemical  examination  and  methods; 
microscopy;  apparatus;  Ehrlich's  aldehyde. 

CHAPTER  V. 

The  Indolic  Type  of  Intestinal  Putrefaction. 

The  primary  stage;  in  childhood;  sources  of  infection;  ascending 
infections;  symptoms;  the  secondary  stage;  dyspepsia,  indigestion, 
nervous  indigestion;  local  disturbances  of  function;  the  special- 
ized organs;  the  gastric  contents;  the  urine;  the  feces;  the  ter- 
tiary stage. 

CHAPTER  VI. 

The  Saccharobutyric  Type  of  Intestinal  Putrefaction. 

Definition;  the  primary  stage;  symptoms;  the  abdominal  organs; 
the  function  of  the  liver;  the  gastric  contents;  the  feces;  the  urine. 


iv  CONTENTS 

CHAPTER  VII. 

The  Acetic  Type  of  Intestinal  Putrefaction. 

Definition;  beta-oxybutyric  acid;  diacetic  acid;  acetone;  the 
primary  stage;  absence  of  alarming  symptoms;  the  secondary 
stage;  acetone  production  without  serious  symptoms;  diacetic 
acid  and  the  liver  function;  chemistry;  the  pancreas;  diabetes; 
glycogen;  sugars  and  starches;  surgical  lesions;  the  nervous  sys- 
tem; the  feces;  the  urine;  the  tertiary  stage. 

CHAPTER  VIII. 

The  Oxalic  Type  of  Intestinal  Putrefaction. 

The  primary  stage;  the  secondary  stage;  symptoms;  chronic 
rheumatism;  the  intermittent  type;  the  feces;  the  urine;  types 
of  molds  found  in  the  feces;  the  tertiary  stage;  moniliasis. 

CHAPTER  IX. 

The  Oleic  Type  of  Intestinal  Putrefaction. 

Intolerance  of  certain  fats;  the  primary  stage;  psychoses;  the  second- 
ary stage;  the  blood;  the  feces;  torulae;  the  urine;  lipase  and 
the  higher  fatty  acids. 

CHAPTER  X. 

The  Ammoniacal  Type  of  Intestinal  Putrefaction. 

The  primary  stage;  the  secondary  stage;  duration  and  symptoms; 
the  urinary  system;  ammonia  in  the  urine;  calculus  formation; 
the  urine;  the  feces;  the  liver;  in  combination  with  saccharo- 
butyric  type. 

CHAPTER  XI. 
The  Uric  Acid  Type  of  Intestinal  Putrefaction. 
Importance  of  intestinal  condition. 

CHAPTER  XII. 
Malaria,  Syphilis  and  Tuberculosis. 

Possibility  of  malarial  infection  in  enterocolitis;  general  consid- 
eration of  malaria  in  New  England;  the  blood;  classification; 
sensitization;  anti-anaphylaxis;  the  course  of  malarial  infections; 
the  four  stages  of  chronic  malaria;  life  history  of  the  Plasmodium; 
the  transmission  without  the  agency  of  the  mosquito;  absence 
of  secondary  stage;  syphilis;  tuberculosis. 


CONTENTS  V 

CHAPTER  XIII. 

The  Protein  Poison. 

Sensitization;  individual  peculiarities  and  susceptibilities;  in 
the  primary  stage  of  enterocolitis;  acute  indigestion;  permeabil- 
ity in  certain  mucosae;  particulate  proteins;  the  three  stages. 

CHAPTER  XIV. 

The  Treatment  of  Enterocolitis. 

In  general;  the  primary  stage;  intestinal  antiseptics;  the  second- 
ary stage;  the  mixed  infections;  the  indolic  type;  the  saccharo- 
butyric  type;  the  oleic  type;  constipation. 

CHAPTER  XV. 

General  Consideration  of  Enterocolitis. 


PREFACE 


In  the  year  1906,  Professor  Herter  published  his  epoch- 
making  work  on  the  Common  Bacterial  Infections  of  the 
Digestive  Tract.  Before  this,  other  medical  thinkers  had 
pointed  out  the  way;  Schmidt  and  Strasburger  had  published 
their  monumental  work  on  the  human  feces  and  Metchni- 
kof¥  had  noted  the  connection  between  intestinal  putrefac- 
tion and  the  duration  of  human  life.  It  remained  for  Herter, 
however,  to  give  the  impulse  that  led  to  the  application  of 
these  discoveries  in  clinical  practice.  It  was  through  his 
classic  teaching  that  physicians  learned  to  use  the  three 
great  weapons:  chemistry,  bacteriology  and  biology,  in  the 
fight.  Various  phenomena  such  as  hyper- and  hypochlorhydria, 
indicanuria  and  autointoxication,  so  called,  fitted  themselves 
into  the  clinical  pictures ;  diseases  that  at  first  sight  seemed  to 
be  intimately  connected  with  faulty  metabolism  in  the  hu- 
man tissues  were  proven  to  arise  not  through  any  parenteral 
biochemical  process  but  in  spite  of  it.  Organic  lesions  were 
given  the  prominent  position  that  they  deserve,  while  the 
various  types  of  intestinal  putrefaction  were  used  as  avenues 
of  information  through  which  a  knowledge  of  the  nature 
and  mode  of  attack  of  the  enemy  might  be  gained. 

In  the  preparation  of  this  book,  that  great  enemy  of  the 
arts,  fleeting  time,  has,  of  necessity,  placed  certain  limita- 
tions upon  the  task.  Its  preparation  has  been  a  labor  of 
great  satisfaction.  By  far  the  greatest  satisfaction,  however, 
rests  in  the  fact  that  what  was  formerly  a  matter  of  conjecture, 
can  through  laboratory  methods  be  brought  to  a  point  of 


viii  PREFACE 

absolute  certainty.     This  should  give  the  physician,  through 

the  directness  of  his  therapeutic  attack,   greater  power  in 

the  battle  with  disease,  and  should  he,  through  the  methods 

set  forth  in  the  following  pages,  win  the  fight,  prolong  the 

useful  life  or  even  alleviate  the  suffering  of  some  unfortunate 

human  being,  the  writer  will  feel  that  his  labors  have  been 

well  repaid. 

The  Author. 

Six  Thomas  Street, 
Providence. 


CHAPTER  1 

ENTEROCOLITIS 


The  course  of  this  disease  may  be  divided  into  three  stages, 
and  these  for  convenience  in  clinical  study  may  be  termed 
primary,  secondary  and  tertiary.  In  the  primary  stage  a 
sudden  onset  accompanied  by  more  or  less  acute  symptoms 
is  the  rule.  The  secondary  stage  is  marked  by  a  period  of 
increasing  gastrointestinal  disturbance,  either  continuous  or 
intermittent,  extending  over  a  considerable  length  of  time. 
The  tertiary  stage  begins  with  the  advent  of  low-grade  in- 
flammatory changes  involving  the  stroma  and  parenchyma 
of  some  organ  or  group  of  organs  of  the  body. 

The  duration  of  the  primary  stage  is  a  matter  of  days, 
that  of  the  secondary  stage  may  be  reckoned  in  years  or 
decades,  while  that  of  the  tertiary  stage  depends  upon  the 
vitality  of  the  organs  involved.  The  primary  stage  may 
begin  in  early  infancy,  in  childhood,  in  adolescence  or  at  any 
time  during  the  life  of  the  patient.  Many  of  the  obscure 
febrile  disturbances  of  infancy  and  childhood,  while  not 
recognized  at  the  time  as  the  beginning  of  a  disease  that  may 
lead  to  inefficiency  and  premature  old  age,  mark  the  begin- 
ning of  a  chronic  enterocolitis. 

Certain  families  seem  especially  liable  to  the  ravages  of 
this  disease  and  upon  questioning  these  patients,  it  will  be 
found  that  their  ancestors  for  many  generations  have  died  of 
diseases  traceable  to  intestinal  putrefaction,  such  as  arterio- 
sclerosis, cirrhosis  of  the  liver  and  other  low-grade  inflam- 
matory disturbances  in  various  specialized  organs,  at  ages 
well  below  sixty. 

Errors  in  diet,  constipation,  overindulgence  in  animal  food 
are  not  of  such  importance  in  the  etiology  of  enterocolitis 


2  INTESTINAL  PUTREFACTIONS 

as  is  the  reduction  of  vitality  incident  to  the  stress  and  com- 
petition of  modern  life  and  the  lack  of  nourishing  food  and 
fresh  air. 

As  the  most  prominent  predisposing  cause,  the  habitual 
use  of  purgatives  and  cathartics,  especially  the  salines, 
may  be  given  a  prominent  position.  The  irritation  of  the 
intestines,  through  the  daily  use  of  sodium  phosphate,  sodium 
sulphate,  magnesium  sulphate  and  potassium  bitartrate  so 
lowers  the  resistance  of  the  intestinal  mucous  membrane  as 
to  encourage  the  invasion  of  the  infecting  micro-organisms. 
Cathartics  of  less  irritating  character  may  also  be  a  very 
prominent   factor   in   the  development  of   this  condition. 

To  the  results  of  emotional  excitement,  grief,  disappoint- 
ment and  other  depressants  of  the  resisting  power,  may  be 
added  the  exposure  to  strains  of  bacteria  with  which  the 
patients  were  not  accustomed  to  deal. 

Before  beginning  the  treatment  of  these  patients,  three 
diagnoses  should  be  made: 

First:  The  anatomical  diagnosis,  dealing  with  the  nature 
and  extent  of  the  alimentary  catarrhal  process,  the  position 
of  the  abdominal  viscera  and  the  condition  of  the  liver,  heart, 
kidneys  and  other  internal  organs. 

Second:  A  chemical  diagnosis  directed  to  estimating  the 
patient's  capacity  for  oxidizing  acids  and  toxins  and  to  deter- 
mine the  nature  of  the  intoxication. 

Third:  A  biological  diagnosis  covering  the  character  of 
the  intestinal  fauna,  and  the  presence  of  parasites  in  the 
tissues  of  the  body. 

Primary  Stage. 

In  the  primary  stage  the  clinical  picture  is  one  of  acute 
infection.  There  may  be  a  rise  in  temperature  preceded  by 
a  chill,  anorexia  and  vomiting.  The  local  symptoms  may 
not  be  pronounced  but  pains  in  various  portions  of  the  ab- 
domen are  prominent  if  the  colon  is  markedly  involved. 
These  pains  are  generally   referred   to  some  of  the  flexures 


ENTEROCOLITIS  3 

of  the  large  intestine.  If,  however,  parts  of  the  alimentary 
canal  higher  up  are  affected  the  pain  is  referred  to  the  epi- 
gastrium. Often  mucous  stools,  stained  saffron  yellow,  will 
be  noted.  This  disturbance  may  vary  in  severity  from  one 
so  slight  as  to  pass  unnoticed  to  toxemia  so  overwhelming 
as  to  cause  sudden  death.  Other  subsequent  attacks  do 
not  generally  equal  the  first  in  severity.  There  may  be 
constipation  or  diarrhoea. 

Secondary  Stage. 

Convalescence  from  the  primary  stage  of  this  disease  may 
appear  to  the  patient  to  be  complete.  A  chemical  or  micro- 
scopical examination  of  the  patient's  feces,  urine  and  blood, 
however,  will  show  that  a  marked  change  has  taken  place. 
That  a  condition  has  developed  that  if  allowed  to  go  on,  will 
eventually  impair  the  usefulness  of  the  victim,  or  lead  to  a 
premature  decay  of  some  or  all  of  the  functions  of  his  body. 
Unlike  the  primary  stage,  this  is  of  long  duration,  running 
a  course  of  years  or  even  decades.  It  is  a  stage  when  changes 
generally  take  place  gradually,  when  like  the  mills  of  the 
gods  the  grinding  process  is  slow  but  the  grist  exceeding  fine. 
Ten,  twenty  or  even  thirty  years  may  pass  before  a  vital 
organ  begins  to  suffer  changes,  but  these  changes  are  as  sure 
to  come  as  the  changes  of  the  seasons. 

This  stage  is  characterized  by  dyspeptic  symptoms,  de- 
scribed by  the  patient  as  severe  or  slight,  as  the  suscepti- 
bility or  resistance  of  the  individual  may  vary.  These  com- 
plaints may  be  transitory  or  continuous. 

It  is  unfortunate  that  the  gastro-enteric  mucosa  is  not 
more  liberally  endowed  with  the  sense  of  pain  and  that  very 
few  intestinal  lesions  give  this  symptom  in  a  marked  degree 
until  the  disease  has  progressed  far  enough  to  involve  the 
muscular  or  peritoneal  coat.  The  intestinal  mucosa  often 
suffers  such  damage  that  the  nutrition  of  the  individual  is 
irreparably  undermined,  with  no  other  alarming  symptom, 
perhaps,  than  a  more  rapid  loss  of  flesh  than  a  dyspepsia 
might  cause. 


4  INTESTINAL  PUTREFACTIONS 

The  symptoms  and  physical  signs  of  this  stage  may  be 
classified  as  general  and  local.  The  general  symptoms  arise 
from  the  attack  of  toxins  upon  the  patient's  tissues,  causing 
irritation  and  depression  of  vitality  in  various  organs,  or 
groups  of  organs.  Bearing  this  in  mind,  the  various  clinical 
pictures  met  with  in  this  stage,  can  be  easily  composed  and 
their  great  variety  fully  explained. 

From  the  patient's  standpoint  the  course  of  the  disease  is 
not  continuous.  At  the  time  of  the  acute  attacks  he  is  in 
misery:  during  the  periods  of  remission,  he  enjoys  compara- 
tive comfort.  Each  attack,  however,  leaves  a  certain  amount 
of  damage  behind  it,  varying  in  amount  with  the  natural 
resistance   of   the  affected   organ. 

Locally,  a  train  of  symptoms  and  physical  signs  presents 
itself  that  has  its  origin  in  the  direct  irritation  of  the  intes- 
tinal mucosa.  Spasms,  which  may  reach  the  point  of  pro- 
ducing intense  pain,  referred  to  the  pylorus,  the  stomach 
or  the  intestines  are  common.  The  pylorus  is  the  most 
frequent  site  of  this  disturbance,  apparently  arising  from  the 
effort  of  the  intestine  to  protect  itself  from  the  irritation  of 
the  acid  stomach  contents.  This  may  become  so  persistent 
as  to  lead  to  continuous  nausea  or  prolonged  vomiting. 
Spasms  of  the  colon  are  next  most  frequently  encountered, 
and  often  lead  to  spastic  constipation  with  triangular,  rib- 
bon-like or  scybalous  stools  of  small  calibre,  and  consider- 
able pain  and  tenesmus. 

While  the  symptoms  in  this  Secondary  Stage  may  be  so 
mild  as  to  escape  ordinary  notice,  yet  a  patient  in  this  con- 
dition of  comparative  comfort,  may  be  in  even  greater  danger 
than  one  showing  the  most  pronounced  symptoms.  How 
often  have  we  noted  a  change  in  physical  condition  gradually 
develop  in  certain  people.  They  do  not  consider  themselves 
ill,  they  manage  to  perform  their  daily  tasks  with  satisfaction 
to  themselves  and  to  their  employer,  and  complain,  if  they 
complain  at  all,  only  of  a  slight  lack  of  their  former  endur- 
ance; yet  they  do  not  appear  to  be  in  perfect  health.  To 
the  practiced  eye,  their  illness  may  be  diagnosed  offhand  as 


ENTEROCOLITIS  5 

progressive  anemia  of  obscure  origin,  and  eventually  they  die 
suddenly  of  cardiac,  renal  or  hepatic  diseases  which  are  as- 
cribed, perhaps,  to  overwork.  The  long-standing  intestinal 
putrefaction,  which  was  the  direct  cause  of  their  untimely  end, 
is  usually  overlooked. 

Tertiary  Stage. 

When  organic  lesions  of  any  organ  can  be  demonstrated 
clinically,  the  Tertiary  Stage  may  be  said  to  begin.  For 
some  time  before  this,  however,  organic  changes,  though  not 
apparent  upon  physical  examination,  have  been  slowly 
advancing. 

The  onset  of  this  stage  may  be  either  gradual  or  extremely 
sudden.  In  the  latter  case,  a  diagnosis  of  acute  inflammation 
is  often  erroneously  made.  If  of  sudden  onset,  the  symp- 
toms may  be  very  violent  and  often  so  severe  as  to  cause 
death.  The  fact  should  be  borne  in  mind,  however,  that 
the  lesions  in  the  kidney,  heart,  blood  vessels  or  other  special- 
ized organs  have  not  arisen  de  novo,  but  as  the  result  of  a 
long-standing  toxemia. 

If  the  onset  of  this  stage  is  gradual  very  few  symptoms 
will  at  first  be  given.  More  often,  however,  the  presence 
of  some  physical  signs  discovered  in  the  course  of  the  exam- 
ination of  the  urine,  feces  or  blood,  or  in  the  physical  exam- 
ination of  the  patient  will  disclose  the  fact  that  the  fight  is 
lost.  In  other  individuals  the  sudden  cessation  of  improve- 
ment or  a  rapid  loss  of  strength  and  endurance  show  only 
too  plainly  the  beginning  of  some  organic  changes. 

In  the  case  of  individual  organs,  the  importance  of  these 
to  life  may  have  a  great  bearing  upon  the  subsequent  course 
of  the  disease.  Lesions  is  such  organs  as  are  intimately 
connected  with  digestion,  metabolism  and  excretion  naturally 
have  a  most  deleterious  effect  upon  intestinal  catarrhs  and 
putrefactions.  Failure  of  the  organs  of  circulation  may 
bring  on  passive  congestions  or  anemias  that  preclude  the 
possibility  of  any  improvement  in  intestinal  conditions. 
The  function  of  the  nervous  mechanism  of  the  viscera  may 


6  INTESTINAL  PUTREFACTIONS 

be  so  damaged  as  to  upset  the  balance  of  the  various  abdom- 
inal organs  and   to   impair   their  vitality. 

Death  may  result  from  the  failure  of  some  organ  necessary 
to  life  or  the  result  of  some  intercurrent  disease  to  which 
the  patient's  weakened  condition  opens  the  way. 


CHAPTER    II 

THE   MICRO-ORGANISMS  OF  THE 
INTESTINAL    CANAL 


The  micro-organisms  that  are  the  causative  agents  in 
chronic  catarrhal  processes  affecting  the  gastro-intestinal 
canal  and  the  various  passages  connecting  therewith,  offer 
a  field  for  study,  that  up  to  the  present  time,  has  been  very 
lightly  cultivated.  Limited  as  is  the  field  in  most  cases  to 
the  study  of  the  feces,  the  fauna  of  the  higher  parts  of  the 
intestinal  lumen,  in  the  human  subject  at  least,  is  extremely 
difficult  to  investigate.  As  these  diseases  are  rarely,  per  se, 
fatal,  the  patient's  death  being  the  result  of  the  secondary 
changes  taking  place  in  some  distant  organ,  we  must  of  neces- 
sity rely  upon  specimens  taken  at  the  time  of  operation  upon 
the  upper  intestinal  canal  or  upon  the  gall  ducts  for  our 
information.  Deductions  from  the  chemical  findings  in  both 
feces  and  urine  have  been  found  of  great  assistance  in  throw- 
ing light  upon  the  character  of  the  infective  process.  For 
example,  the  presence  of  a  very  strong  reaction  to  Ehrlich's 
aldehyde  in  the  feces  leads  us  to  suspect  a  luxuriant  growth 
of  the  short,  plump  bacillus,  which  in  pure  culture  gives  a 
remarkably  sharp  response  to  this  test,  in  the  duodenum 
and  jejunum,  even  if  these  bacilli  have  disappeared  by  the  time 
the  fecal  specimen  reaches  the  laboratory  for  examination. 

From  the  clinical  standpoint  the  vegetable  parasites  of  the 
intestinal  canal  and  the  passages  directly  connected  with  it, 
may  be  divided  into  three  classes: 

1.  Those  which,  gaining  access  to  the  intestine,  invade 
the  tissues  of  the  host. 

2.  Those  which  feed  upon  the  epithelium  of  the  mucus 
membrane  of  the  intestine  and  rarely  penetrate  more 
deeply  into  the  tissues. 


8  THE  MICRO-ORGANISMS 

3.  Those  which  grow  in  the  contents  and  the  mucus 
covering  the  surface  of  the  intestinal  canal  and  do  not 
directly  attack  the  mucous  membrane. 

The  group  of  intestinal  infections  herein  described  belong 
to  parasitism  of  the  third  class  and  include  the  bacteria, 
hyphomycetes  and  saccharomycetes. 

The  effect  of  the  growth  of  micro-organisms  may  be  clas- 
sified as  follows : 

1.  The  direct  parasitic  effect:  diversion  of  food  supply, 
chemical  changes  in  the  chyle,  rendering  it  unfit  for  absorp- 
tion. 

2.  The  production  of  toxic  by-products,  such  as  acids 
and  acid  salts,  aromatic  bodies,  protein  bodies,  ethereal 
sulphates,  ammonia. 

3.  The  effect  upon  the  organs  directly  concerned  in 
internal  metabolism,  including  overwork  in  oxidizing 
acids,  ethereal  sulphates,  etc.,  and  the  direct  toxic  effect, 
leading  to  structural  changes  in  distant  organs. 

Changes  in  these  organs  may  be  classified  as  follows: 

In  the  parenchyma:  hyperplastic  and  increased  function, 
atrophic  and  diminished  function. 

In  the  stroma:  hypertrophy,  fibrosis,  degeneration,  con- 
traction, cirrhosis,  calcification. 

These  changes  may  involve  cardiac,  arterial,  hepatic,  renal, 
gastro-intestinal,  nervous,  muscular,  articular,  ovarian,  pan- 
creatic or  any  of  the  various  forms  of  animal  tissue,  with  a 
syndrome  corresponding  to  the  special  type  of  degeneration. 

The  animal  parasites  of  the  intestinal  canal  are  without  the 
matter  under  discussion  and  will  only  be  mentioned  when 
their  presence  has  some  bearing  upon  the  subject  at  hand. 

As  the  putrefactive  processes  of  the  alimentary  canal  are 
studied  clinically  and  in  the  laboratory,  the  questions  often 
arise.  Why  do  the  contents  of  the  normal  human  intestine 
remain  so  nearly  sterile  ?  Why,  in  normal  stools,  do  we 
find  so  few  micro-organisms  of  the  putrefactive  type  and 
such    a  luxuriant   growth   of   the   bacillus    communis    coli  ? 


OF  THE  INTESTINAL  CANAL  9 

We  find  also  that  feces  kept  in  an  incubator  for  days  do  not 
undergo  a  great  change  in  their  bacterial  fauna;  that  outside 
of  an  increase  in  the  number  of  the  special  types  present 
when  that  stool  was  passed,  even  after  the  specimen  has  been 
exposed  to  contamination  in  the  laboratory,  very  few  new 
types  of  micro-organisms  develop. 

The  feces  of  infants  may  be  kept  in  a  temperature  of  98.6°F. 
for  a  week  or  more  without  change  and  even  the  addition  of 
such  feces  to  culture  media  will  check  the  growth  of  certain 
micro-organisms.  * 

There  seems  to  be  some  antiseptic  present  in  normal  feces 
that  has  a  specific  or  selective  action  against  the  "wild" 
strains  of  bacteria.  This  body  is  probably  secreted  by  the 
liver  and  pancreas  and  by  the  intestinal  mucosa  and  in  health 
keeps  all  bacteria  in  check,  except  the  colon  bacillus  peculiar 
to  the  genus  homo.  The  strength  or  power  of  this  antiseptic 
varies  inversely  with  the  age  of  the  individual  and  by  gauging 
its  strength  an  accurate  estimate  of  the  relative  age  can  be 
made. 

An  intestinal  catarrh  gives  very  little  trouble  until  this 
antiseptic  begins  to  be  diminished  in  amount  or  in  strength, 
and  in  no  case  can  recovery  be  considered  complete  until 
repeated  examinations  of  the  feces  show  that  this  function 
has  been  regained  to  an  extent  commensurate  with  the  age  of 
the  individual.  If  the  antiseptic  body  could  be  produced 
synthetically  or  by  extraction,  it  could  be  truly  said  that  one 
of  the  springs  of  life  had  at  last  been  found. 

Putrefaction  is  never  present  in  the  intestinal  canals  of 
normal  animals  and  when  found  is  always  an  evidence  of 
disease.  When  present,  we  may  assume  an  impairment  of 
the  antisepticus  intestinalis  in  the  chyle  and  feces.  This 
antiseptic,  as  we  said  before,  is  selective  for  every  type  of 
bacteria  with  which  the  organism  habitually  comes  in  contact, 
except  the  colon  bacillus. 

There  are  several  conditions  that  may  weaken  or  depress 
the  secretion  of  this  antiseptic — 


*Herter,  Com.  Bac,  Inf.  Digestive  Tract,  p.  13. 


10  THE  MICRO-ORGANISMS 

(a)  The  general  reduction  of  vitality  through  grief, 
pain  and  misfortune. 

(b)  The  attack  of  toxins,  such  as  those  produced  in 
the  growth  of  B.  tuberculosis,  treponema  pallida, Plasmodium 
malariae  and  other  micro-organisms. 

(c)  The  direct  effect  of  catarrhal  processes  upon  the 
mucosa. 

To  thoroughly  comprehend  the  process,  the  intestinal 
canal  must  be  regarded  as  a  hollow  organ  continuous  with 
other  external  epithelial  surfaces  of  the  body.  The  contents 
of  the  intestine  are,  in  consequence,  as  much  outside  the 
body  as  the  water  in  which  we  wash  our  hands.  There  is  a 
marked  difference,  however,  between  the  mucous  membrane 
and  the  skin  and  this  is  in  the  rate  of  absorption.  While 
this  for  many  chemical  bodies  is  fairly  active  on  cutaneous 
surfaces,  on  the  intestinal  surface  it  is  of  extreme  activity. 
This  fact  is  taken  advantage  of  by  the  bacteria  of  intestinal 
putrefaction,  which  by  their  toxins  and  aggressins  still  fur- 
ther reduce  the  vitality  of  the  body  tissues. 

The  vegetable  parasites  may  be  considered  under  the  follow- 
ing heads:  (1)  Bacteria,  (2)  Hyphomycetes  or  molds,  (3) 
Saccharomycetes  or  yeasts.  While  this  classification  may 
not  be  strictly  and  scientifically  accurate,  still  it  answers  all 
the  requirements  of  clinical  study. 

The  following  list  of  bacteria,  according  to  the  classifica- 
tion of  Chester  will  be  found  of  great  service  in  the  study 
of  this  subject  in  the  laboratory.  This  list  gives  most  of 
the  bacteria  encountered  in  this  class  of  work  and  for  con- 
venience of  reference  the  number  given  in  Chester's  valuable 
work  is  prefixed. 

1.     BACTERIA: 

A .     Streptococcus : 

2.     Str.  enteritis  Hirsch. 
7.     Str.  enteritidis  Escherich. 
10.     Str.  canis. 


OF  THE  INTESTINAL  CANAL  11 

11.     Str.  coli. 
15.     Str.  lactis. 

B.  Micrococus: 

6.  M.  pyogenes  albus. 
20.     M.  aerogenes  Miller. 
22.     M.  alvi. 

27.     M.  Mendozae. 

34.  M.  cumulatus  v.  Besser. 

35.  M.  salivarius  Biondi. 

43.  M.  ovalis  Escherich. 

44.  M.  lactis. 

45.  M.  candicans. 

61.  M.  subflavus  V.  Besser. 
64.     M.  pyogenes  aureus. 

C.  Sarcina : 

1.  Sarc.  pulmonum. 

4.  Sarc.  flava. 

5.  Sarc.  lactis. 

7.  Sarc.  lutescens  Stubenrath. 
9.  Sarc.  lutea. 

11.  Sarc.  cervina  Stubenrath. 

12.  Sarc.  fusca  Gruber. 

D.  Planococcus: 

E.  Planosarcina : 

3.     P.  Sarc.     Samesii. 

F.  Bacterium: 
10.     Bact.  aceti. 

17.  Bact.  acetigenum. 

18.  Bact.  aceticum. 

20.  Bact.  aerogenes. 

21.  Bact.  capsulatum. 
57.  Bact.  Bienstockii. 

62.  Bact.  dysenteriae. 
71.  Bact.  lactis. 

166.     Bact.  Welchii. 


12  THE  MICRO-ORGANISMS 


166. 

Bact.  aerogenes  capsulatus. 

171. 

Bact.  thermophilum. 

210. 

Bact.  subtiliforme. 

211. 

Bact.  simile. 

Bact.  Mellanby  &  Twort.* 

G.    Bacillus: 

2. 

B.  coli. 

5. 

B.  enteritidis. 

21. 

B.  typhosus. 

Zd>. 

B.  alcaligenes. 

37. 

B.  Friedbergensis. 

39. 

B.  Schafferi. 

65. 

B.  Shigae. 

75. 

B.  bucalis. 

84. 

B.  tachyctonus. 

113. 

B.  dysenteriae.     Kruse. 

116. 

B.  Wesenbergii. 

142. 

B.  prodigiosus. 

155. 

B.  Lesagei. 

194. 

B.  subtilis. 

238. 

B.  putrificus. 

243. 

B.  car  is. 

245. 

B.  solidus. 

250. 

B.  botulinus. 

251. 

B.  butyricus  Botkin. 

252. 

B.  amylobacter — Clostridium  butyn 

254. 

B.  Kedrowskii. 

256. 

B.  sporogenes. 

B.  bifidus  (vide  Herter  p.  41). 

B.  acidophilus. 

B.  acidolacticus. 

B.  anthracis  symptomatic!. 

B.  cloacae. 

B.  entericus. 

B.  liquefaciens  ilei. 

*Protein'Split  Products,  Vaughn,  1913,  p.  294. 
Journal  Physiol.  1912,  XLV,  53. 


:    ,  OF  THE  INTESTINAL  CANAL  13 

B.  mascerans. 
B.  violarius  acetonicus. 
B.  oedematis  maligni. 
B.  paraputrificus. 
B.  proteus  vulgaris. 

H.     Pseudomonas: 

2.     Ps.  monadiformis. 
29.     Ps.  capsulata. 

/.     Microspira: 
6.     Msp.  comma. 

10.  Msp.  protea. 

/.     Spirillum: 

2.  Sp.  Massauah. 

K.     Spirochaeta: 
L.     Mycobacterium: 

3.  Mycobact.  influenzae. 
9.     Mycobact.  diphtheriae. 

13.  Mycobact.  tuberculosis. 

M.     Streptothrix: 

1.     Streptothr.  bo  vis. 

11.  Streptothr.  chromogena. 

14.  Streptothr.  farcinica. 

N.    Leptothrix: 
M.     Cladothrix: 

6.     C.  intestinalis. 

N.     Thiothrix: 
0.    Beggiatoa: 

2.  HYPHOMYCETES  OR  MOLDS.  In  the  more  severe 
types  of  enterocolitis  the  fecal  fields  regularly  show  the 
presence  of  this  class  of  micro-organisms.  A  great  deal  of 
work  remains  to  be  done  among  the  members  of  the  fungi 
of  this  group  that  are  parasitic  in  the  intestinal  canal. 


14  THE  MICRO-ORGANISMS 

Cultural  experiments  have  shown  the  great  importance 
of  these  fungi  in  the  pathology  of  this  disease.  Their 
biological  processes  are  usually  rapid  and  intense  and 
the  resulting  chemical  bodies  at  times  extremely  toxic  both 
to  the  mucosa  of  the  intestinal  canal  and  to  the  general  body 
parenchyma.  The  enzymes  that  they  use  in  gaining  their 
livelihood  are  of  great  activity,  are  very  diffusible  and  are 
so  constructed  as  to  act  extracellularly.  These  ferments 
attack  starches,  sugars,  cellulose,  proteins,  oils  and  fats  with 
vigor.  The  waste  products  of  the  growth  of  these  micro- 
organisms are  also  important  and  generally  extremely  irri- 
tating. Their  enzymes,  under  certain  conditions,  are  capable 
of  doing  great  damage  to  the  tissues  of  the  body  that  have  a 
fatty  structure,  especially  the  nervous  system.  In  other 
catarrhs  their  damage  arises  not  so  much  through  toxic 
action  as  through  mechanical  obstruction  of  the  absorbing 
surfaces  of  the  intestinal  mucosa.  They  very  generally 
may  be  classed  as  Fungi  Imperfecta 

(a)     Trichothecium : 

Septate,  never  forms  sporangia,  conidiophores  not  united 
into  definite  bodies;  conidia  and  hyphae  never  pigmented. 
Conidia  double  celled,  solitary,  not  in  chains;  both  cells 
smooth;  conidiophores  not  branched;  conidia  at  tip,  never 
on  sides  of  conidiophores;  conidia  spherical  or  pear  shaped, 
two  cells  often  unequal  in  size;  conidiophores  long. 
(Buchanan.) 

In  sprue  in  Gram  stained  fecal  preparations  the  hyphae 
are  positive,  deeply  stained,  unless  degeneration  has  set  in, 
when  they  are  positive  and  negative  in  sections  or  areas. 
They  are  septate,  the  septa  being  spaced  about  5  microns. 
The  stroma  stains  granularly  with  here  and  there  punctate 
nuclear  matter.  Branching  is  not  noted.  The  hyphae  shows 
a  tendency  to  bend  at  the  septa  in  more  or  less  obtuse  angles. 
They  occur  in  felted  masses  or  in  twisted  strands,  strongly 
resembling  silk  floss.  The  length  of  the  hyphae  is  usually 
30-40  microns,  the  diameter  1.5  to  2.0  microns. 

The  conidia  are  double  celled,  solitary,  never  in  chains. 


OF  THE  INTESTINAL  CANAL  15 

Both  cells  are  smooth,  conidiophores  not  branched,  conidia 
borne  on  the  tip,  never  on  sides  of  conidiophores.  The  cells 
are  pear  shaped  and  are  unequal  in  size;  the  conidiophores 
are  long,  with  constrictions  spaced  about  eight  times  their 
breadth;  the  dimensions  average  3.6x1.5  microns. 

This  apparently  is  a  member  of  the  family  Mucedinaceae, 
genus  Trichothecium. 

(b)     Monilia: 

Conidia  never  borne  in  sporangia;  mycelium  septate; 
conidiophores  never  united  into  definite  bodies;  hyphae 
and  conidia  never  colored  or  smoky;  conidia  one  celled,  never 
multi-celled;  conidiophores  never  sharply  differentiated  from 
mycelia,  sometimes  lacking.  Conidia  develop  by  breaking 
up  of  hyphae.  Conidia  develop  on  definite  branches;  myce- 
lium well  developed  and  compact. — (Buchanan.) 

In  the  fecal  fields,  this  mold  occurs  as  a  rod  about  6x1 
microns  with  square  ends.  The  ends  are  usually  Gram  pos- 
itive. The  body  of  the  micro-organism  is  Gram  negative 
with  one  streak  of  Gram  positive  matter  along  the  side.  The 
conidia  are  cuboidal  in  form,  and  are  capsulated  with  une- 
venly stained  protoplasm.  Their  dimensions  are  approxi- 
mately  1x2   microns. 

The  monilia  grow  luxuriantly  on  glucose  nutrient  agar 
media.  The  mycelia  are  compact,  branching,  positive  or 
negative  to  Gram  stain,  according  to  their  age.  They  are 
cuboidal  in  shape,  with  dark.  Gram  positive  lines  across  the 
ends  of  the  hyphae  and  many  of  the  hyphae  have  on  the 
side  a  Gram  positive  line,  as  in  the  types  found  in  the  feces. 
The  hyphae  are  4  microns  in  diameter,  septate  and  branch- 
ing. Smaller  aerial  hyphae,  the  tips  breaking  into  square- 
end  oidia,  4x7  microns  in  diameter,  will  be  noted.  The 
cuboidal  structure  of  the  mold  is  very  characteristic.  The 
hyphae  and  conidia  are  coated  with  mucus.  Grown  under 
anaerobic  conditions,  the  hyphae  and  conidia  are  smaller 
and  approach  more  nearly  to  the  type  found  in  feces.  Con- 
siderable gas  is  produced  in  growth  under  these  conditions. 


16  THE  MICRO-ORGANISMS 

(c)     Torula: 

Family  Dematiaceae :  conidia  never  borne  in  sporangia; 
septate  mycelia;  hyphae  and  conidia  are  both  dark  or 
smoky;  conidia  never  spiral  or  radiate;  mycelium  little  devel- 
oped, breaking  into  oidia,  or  on  short  lateral  hyphae;  conidia 
in  chains  easily  broken  apart  into  free  conidia.  If  the  co- 
nidial  chains  are  not  easily  broken  apart,  genus  Hormiscium. 
— (Buchanan.) 

In  the  fecal  fields  torulae  when  young  are  strongly  Gram 
positive  and  take  the  form  of  hyphae  of  medium  size,  1.50  to 
2.00  X  10  to  30  microns.  As  they  develop,  slight  indenta- 
tions appear  along  the  edges.  In  the  shorter  ones,  con- 
sisting of  two  elements,  this  gives  the  micro-organisms  a 
"dumbbell"  form.  As  the  chains  grow  older,  the  bodies  of 
the  conidia  become  negative  with  Gram  positive  dots  at 
either  pole.  Often  a  constriction  is  noted  in  the  middle 
portion  of  the  conidia,  giving  a  dumbbell  form,  with  nega- 
tively staining  body  and  two  polar  Gram  positive  bodies. 
The  conidial  chain  may  contain  as  many  as  twenty  conidia. 
Occasionally  the  hyphae  of  these  torulae,  in  which  conidial 
division  has  not  occurred,  may  be  observed.  These  are 
septate,  usually  Gram  negative  or  delicately  positive,  with 
a  small  positive  dot  in  the  central  zone  of  each  section. 

In  glucose  media  the  growth  of  these  torulae  is  very  luxuri- 
ant. At  the  end  of  four  or  five  days,  at  room  temperature, 
a  fuzzy,  slimy  growth  starts  out  from  the  line  of  feces  with 
which  the  media  is  sown.  Under  the  microscope  a  few  hyphae 
will  be  observed.  These  measure  2x4  microns  to  3  x  50 
microns,  are  usually  broader  at  one  end  than  the  other  and 
take  a  delicate  blue  tint  with  Gram  stain.  Many  of  the 
hyphae  will  be  seen  dividing  into  conidia.  They  are  usually 
found  in  mycelia,  consisting  of  two  or  three  elements,  rarely 
more.  The  conidia  are  fusiform,  one  celled;  capsulated, 
1.9  to  2.5x3.5  to  7.5  microns,  many  showing  Gram  positive 
polar  dots  and  areas.  Neither  the  conidia  nor  the  hyphae 
have  a  mucous  coating.  With  iodine  they  stain  yellow  with 
clear  areas. 


OF  THE  INTESTINAL  CANAL  17 

In  certain  putrefactions  where  the  presence  of  fatty  acid 
crystals  in  the  stools  is  especially  marked,  this  micro-organism 
is  very  abundant  in  the  fecal  fields  and  seems  to  vary  in  num- 
ber with  the  severity  of  the  intestinal  condition.  The  reader 
is  referred  to  the  chapter  on  Oleic  Putrefaction  for  further 
information, 

(d)  Sporotrichum. 
Septate,  never  forming  sporangia,  conidiophores  never 
united  into  definite  bodies;  conidia  and  hyphae  never 
pigmented;  conidia  single  celled,  conidiophores  sharply 
differentiated  from  the  mycelium,  conidiophores  branched 
or  unbranched,  but  conidia  never  forming  a  terminal  head, 
hyphae  never  whorled,  branched  and  conidia  produced 
irregularly  on  lateral  conidiophores,  never  from  minute  teeth ; 
conidiophores  are  never  upright. — (Buchanan.) 

3.     SACCHAROMYCETES  OR  YEASTS: 

A  host  of  yeasts  gain  their  livelihood  in  the  contents  of  the 
intestinal  canal.  Whether  their  presence  in  the  intestines 
is  harmful,  or  whether  they  may  be  regarded  as  benign,  is 
an  open  question.  We  observe,  however,  that  the  greater 
their  abundance,  the  more  severe  the  sickness  and  also  that 
the  predominance  of  the  round-cell  type  is  an  unfavorable  sign. 
There  has  been  a  great  deal  of  work  done  with  these  micro- 
organisms in  connection  with  the  brewing  and  wine  industry, 
but  at  present  our  knowledge  of  the  pathogenic  varieties, 
with  the  exception  of  those  invading  the  tissues,  is  fragmentary. 

The  position  that  they  may  occupy  in  certain  symbiologi- 
cal  putrefactions  is  important.  In  this  connection  their 
presence  in  many  feces  from  individuals  showing  a  marked 
increase  in  acetone  production,  is  interesting. 

Many  strains  are  known  to  produce  bodies  of  extremely 
disagreeable  taste  and  odor  and  as  materials  repulsive  to  the 
olfactory  system  of  humanity  are  not  generally  well  born, 
either  enterally  or  parenterally,  an  abundant  growth  of 
Saccharomycetes  in  the  intestinal  canal  is  always  viewed 
with  suspicion. 


CHAPTER  III 
THE   EXAMINATION   OF   FECES 


Laboratory  workers  very  generally  regard  the  examination 
of  fecal  matter  as  disgusting  in  the  extreme.  When,  however, 
this  subject  is  approached  in  a  true  scientific  spirit,  these 
investigations  lose  their  repulsiveness  and  are  no  more  dis- 
agreeable than  many  other  things  that  must  be  done  in  the 
pursuit  of  science. 

The  best  container  for  fecal  specimens  is  a  wide-mouthed 
preserve  jar,  fitted  with  the  ordinary  cover  and  rubber  ring. 

For  the  safety  and  convenience  of  the  laboratory  force, 
jars  with  insecure  covers,  jelly  glasses  and  specimens  mixed 
with  water,  toilet  paper  and  urine  should  be  refused.  It 
is  customary  after  finishing  the  examination  of  a  specimen 
to  sterilize  with  formaldehyde  solution.  The  contents  of 
the  jars  are  then  thrown  into  the  watercloset  and  the  jar 
thoroughly  washed.  The  jars  are  then  broken  to  avoid  the 
possibility  of  further  use  and  to  save  storage  space,  packed 
away  in  barrels  to  be  removed  by  the  ash  man  at  his  next  visit. 

The  result  of  the  examination  is  carefully  recorded  and 
the  stained  microscopical  preparations  are  preserved  for 
future  reference  in  ordinary  slide  boxes. 

Upon  the  receipt  of  a  specimen  the  name  and  date  are 
immediately  recorded  in  the  laboratory  register  and  given 
a  number  which  is  pasted  upon  the  container.  This  number 
is  recorded  in  the  history  of  the  patient,  affixed  to  the  speci- 
mens taken  for  preservation  and  carried  in  the  record  of  all 
cultures.  The  result  of  the  examination  is  recorded  on  the 
history  card  of  the  patient  under  the  following  heads: 

1.  Macroscopic. 

2.  Chemical. 


THE  EXAMINATION  OF  FECES  19 

3.  Microscopic. 

(a)  In  water. 

(b)  With  Lugol's  solution. 

(c)  With  Gram's  stain. 

(d)  With  carbol-thionine  stain. 

(e)  With  iodine  stain  (full    strength    Lugol's    solu- 

tion). 

(f)  With  carbol-fucine  stain. 

4.  The  Diagnosis. 

Under  the  heading  macroscopic  examination,  the  follow- 
ing facts  are  recorded: 

(a)  The  form:  sausage-shaped;  scybalous;  soft;  soft  with 
scybalae;  broken;  fibrous;  spongy;  fermenting;  creamy; 
creamy  solidifying  upon  cooling;  liquid;  liquid  with  solid 
portions  or  scybala;  granular;  serous;  watery;  bloody. 

(b)  The  color:  brown;  reddish  brown;  brownish  yellow; 
yellow-brown;  yellow;  grayish  yellow;  gray;  light  gray  or 
clay  color ;  black ;  green ;  olive. 

(c)  Mucus : Khs,enc&;  presence;  amount;  jelly-like;  glairy; 
mucopurulent;  tapioca-like;  masses  free  or  intimately  mixed; 
bloody;  bile-stained. 

(d)  Gross  .particles:  presence  or  absence;  soap  masses; 
enteroliths,  intestinal  sand. 

(e)  Parasites:  presence  or  absence;  kind;  condition. 

(f )  The  odor :  aromatic ;  stinking ;  butyric ;  acetic ;  musty ; 
ammoniacal;  ether-like. 

Chemical  examination : 

This  includes  as  a  routine  measure  the  tests  for  blood, 
for  acidity  and  the  estimation  of  the  reaction  to  Ehrlich's 
aldehyde. 

For  occult  blood  the  benzidin,  acetic  acid,  hydrogen  perox- 
ide test  is  usually  employed  as  the  most  convenient.  The 
aloin  or  guiac  test  may  be  used,  if  preferred. 

All  of  these  tests  are  valueless  unless  that  patient  has  been 


20  THE  EXAMINATION  OF  FECES 

on  an  iron  free  diet  for  several  days.  Therefore  all  kinds 
of  meat,  green  vegetables  and  medicines  containing  iron 
should  be  excluded  from  the  dietary  for  at  least  forty-eight 
hours  before  taking  the  specimen. 

This  test  may  be  performed  in  a  test  tube.  It  is  more 
convenient,  however,  to  use  a  shallow  glass  vessel,  such  as  a 
Petri  dish,  as  in  the  case  of  very  delicate  reactions  it  is  con- 
venient to  examine  with  the  microscope  for  particles  positive 
to  benzidin. 

The  benzidin  should  be  fresh  and  the  acetic  acid  pure. 
Contamination  with  any  vessels  stained  with  any  prepara- 
tion of  iron  should  be  carefully  avoided.  A  small  piece  of 
the  feces  under  examination  is  placed  in  a  Petri  dish,  a  little 
to  one  side  of  the  centre.  This  is  mixed  with  an  equal  amount 
of  hydrogen  peroxide.  A  small  amount  of  benzidin  is 
placed  on  the  opposite  side  of  the  dish  and  mixed  with  two 
or  three  drops  of  concentrated  acetic  acid.  Then  with  a 
clean  glass  rod  the  two  mixtures  are  brought  in  contact.  If 
blood  is  present  in  any  amount  the  customary  green  tint 
will  be  observed  at  the  juncture  of  the  feces,  hydrogen  perox- 
ide mixture  and  the  benzidin  acetic  acid  solution.  If  no 
color  is  apparent  to  the  naked  eye,  the  specimen  may  be 
examined  with  the  microscope  for  the  presence  of  green- 
colored  particles,  denoting  the  presence  of  blood  in  minute 
amounts. 

The  reaction  to  litmus  is  then  recorded.  For  the  estima- 
tion of  total  acidity  or  for  total  alkalinity,  one  gramme  of 
the  feces  is  emulsified  with  9  c.c.  of  distilled  water.  The 
reaction  of  this  is  estimated  by  either  ^  HCl  or  ^  NaOH,  as 
the  case  may  require,  using  phenolphthalein  as  an  indicator. 

The  estimation  of  the  value  of  the  response  to  Ehr- 
lich's  aldehyde  is  of  great  importance.  A  comparison  of 
the  strength  of  this  reaction  in  the  feces  with  that  of  the  urine 
gives  an  absolute  value  for  the  efficiency  of  the  liver.  The 
following  is  the  process:  A  clean  beaker  is  first  weighed  and 
the  weight  recorded.  A  mass  of  the  fecal  matter  under 
examination  is  spread  out  in  a  thin  layer  over  the  bottom 
of  the  beaker,  evaporated  to  dryness  on  the  hot-plate  and 


THE  EXAMINATION  OF  FECES  21 

the  beaker  and  contents  weighed  while  still  warm.  The 
weight  of  the  beaker  and  dried  contents,  less  the  weight  of 
the  beaker  alone,  is  then  multiplied  by  100  and  cubic  centi- 
metres of  water  added  to  equal  this  amount.  The  mixture 
is  then  heated  and  stirred  until  solution  takes  place,  drawn 
into  the  1  c.c.  roller  pipette  and  the  aldehyde  solution  No.  2 
titrated,  as  is  described  in  the  chapter  on  the  Urine. 

For  example : 

Weight  of  beaker  and  dried  feces  less 

weight  of  beaker  0.45  grammes. 

Times  100,  equals  45  c.c.  of  H2O  added. 

Under  titration  0.16  c.c.  of  this  solution  causes  5  c.c.  alde- 
hyde solution  No.  2  to  show  a  pink  fluorescence.  Multiply 
by  two  for  value  of  10  c.c.  of  aldehyde  solution.  Result 
0.32  c.c.  is  the  aldehyde  value  of  the  feces. 

The  proteolytic  and  amylolytic  activity  of  the  feces  may 
be  estimated  with  Mett's  tubes,  egg  albumen  and  starch 
paste.  Exhaustive  investigations  upon  the  enzymes  present 
in  the  feces  conducted  in  my  laboratory  have  shown  very 
little  of  practical  value. 

Extensive  chemical  process  for  the  quantitative  estimation 
of  mucus,  mucine,  fats,  proteins,  carbohydrates;  oleic,  butyric, 
acetic,  diacetic,  formic,  propionic,  oxalic  and  other  acids  and 
their  salts;  indol,  phenol,  skatol  and  various  complex  pro- 
ducts of  bacterial  growth  and  biological  activity  may  be 
followed  out,  if  time  permits. 

The  specimen  is  then  prepared  for  examination  with  the 
microscope. 

A  thin  emulsion  of  feces  and  plain  water  or  decinormal 
salt  solution  is  made,  mounted  on  several  slides,  and  care- 
fully searched  for  the  eggs,  oncospherae  or  embryos  of  the 
intestinal  parasites.  This  is  a  very  important  procedure 
and  its  omission  may  lead  to  very  embarrassing  situations. 

One  to  six  slides  are  prepared  with  weak  Lugol's  solution 
as  a  staining  fluid  and  examined  wet. 


22  THE  EXAMINATION  OF  FECES 

Formula:     Dilute  Lugol's  Solution. 

Water  50  c.c. 

KI  0.5  grammes. 

Lugol's  Sol.  5  c.c. 
A  very  speedy  and  convenient  method  is  the  following,  as 
it  avoids  the  use  of  beakers  or  other  containers.  A  drop  or 
two  of  dilute  Lugol's  solution  is  placed  on  a  clean  glass  slide 
and  mixed  with  a  small  particle  of  the  feces  under  examina- 
tion with  the  aid  of  a  small  wood  applicator.  This  can  be 
burned  when  the  operation  is  completed.  Care  must  be 
taken  not  to  have  too  strong  a  mixture  of  feces  and  solution, 
yet  is  it  convenient  to  have  one  portion  of  the  specimen 
rather  thick  to  aid  in  the  search  for  fat  needles  and  fat  sheaves. 
The  mixture  had  better  be  spread  out  in  a  long,  narrow 
strip  over  the  slide,  so  that  the  cover  glass  will  not  become 
wet  on  the  upper  surface  and  soil  the  objective  of  the  micro- 
scope. 

The  preparation  is  first  examined  for  free  starch  and,  if 
present,  the  appearance  and  kind,  whether  potato,  wheat, 
oat,  etc.,  recorded.  Starch  granules  are  stained  blue.  A 
search  is  next  made  for  muscle  fasciculi.  These  will  be  with 
or  without  striae  and  in  either  case  the  fact  should  be  noted- 
Crystals  should  next  be  searched  for.  These  may  be  fatty, 
triple  phosphate,  oxalate  of  lime,  Charcot-Leyden,  iron, 
bismuth  or  the  residue  of  some  drug  administered  to  the 
patient.  The  yeasts  are  next  examined  and  their  character, 
whether  oval  or  round,  and  the  relative  abundance,  recorded. 
The  vegetable  detritus  is  examined  and  its  description  re- 
corded.    Finally  a  search  for  amoebae  is  made. 

Four  cover  glass  preparations  are  then  made,  two  thin 
and  two  thick.  One  of  the  thin  preparations  is  stained  after 
the  method  of  Gram,  the  other  is  stained  with  carbol-thionine. 
One  thick  one  is  stained  with  full  strength  Lugol's  solution, 
the  other  with  carbol-fuchsine. 

Gram's  Method. 
Three  drops  of  aniline  oil  are  shaken  with  10  c.c.  of  water 
and  filtered.     Five  drops  of  a  saturated  alcoholic  solution 


THE  EXAMINATION  OF  FECES  23 

of  gentian  violet  is  added  to  the  aniline  water.  The  speci- 
men is  stained  with  this  solution  for  three  minutes.  The 
stain  is  poured  ofif  and  without  washing  is  flooded  with  Lu- 
gol's  solution,  which  is  allowed  to  act  for  two  minutes,  decol- 
orized with  absolute  alcohol,  counter-stained  with  Bismarck 
brown,  dried  and  mounted  in  Canada  balsam. 

The  Carbolic  Thionine  Blue  (Nicolle)  is  prepared  as  follows: 
Formula:     Thionine  blue         1.0  gramme 

Carbolic  acid  2.5  grammes 

Distilled  water  100  c.c. 

Filter. 

Before  using,  dilute  with  equal  quantity  of  distilled  water 
and  again  filter. 

Stain  the  specimen  fifteen  minutes  with  the  above,  wash 
thoroughly  and  soak  in  tap  water  for  one  half  hour. 

In  this  preparation  the  alkali  forming  organisms  will  be 
stained  dark  blue,  the  acid  producing  violet. 

The  thick  film  is  then  stained  for  fifteen  minutes  with 
Lugol's  solution,  carefully  washed  to  avoid  the  presence  of 
potassium  iodide  crystals  in  the  finished  preparation  and 
mounted  in  Canada  balsam.  The  other  is  stained  with  hot 
carbol-fuchsine,  decolorized  with  ten  per  cent  nitric  acid 
alcohol  and  counter-stained  with  methyl  blue.  Carbol- 
fuchsine  solution  does  not  keep  well  and  we  find  it  a 
great  convenience  in  our  laboratory  to  keep  phenol  solution 
and  the  fuchsine  solution  separate.  The  method  of  staining 
is  as  follows: 

Upon  one  corner  of  the  smear,  a  small  drop  of  concentrated 
phenol  solution  (liquefied  crystals)  is  placed.  One  drop  of 
alcohol  is  then  added  to  complete  the  solution  of  the  phenol. 
Six  drops  of  water  and  one  drop  of  a  saturated  alcoholic 
solution  of  fuchsine  are  placed  on  the  smear.  This  is  heated 
until  the  liquid  begins  to  steam,  allowed  to  stand  for  ten 
minutes,  decolorized  with  nitric  acid  alcohol,  counter-stained 
with  methyl  blue,  dried  and  mounted  in  Canada  balsam. 

Micro-organisms  are  never  named  in  the  history  card 
unless  a  full  identification  through  cultural  methods  has  been 


24  THE  EXAMINATION  OF  FECES 

carried  out.  The  record  of  the  description  and  not  of  the 
name  has  been  found  of  the  greatest  convenience.  As  our 
knowledge  of  the  micro-organisms  that  are  parasitical  in  the 
intestinal  contents  grows,  records  and  specimens  can  be 
gone  over  again  and  very  useful  information  acquired  from 
the  study. 

The  description  of  the  various  types,  however,  is  recorded 
very  fully  and  covers  the  following  points: 

(a)  The  groups:  streptococcus,  micrococcus,  sarcina, 
planococcus,  planosarcina,  bacterium,  bacillus,  pseudomona, 
microspira,  spirillum,  mycobacterium,  streptothrix,  lepto- 
thrix,  cladothrix,  thiothrix,  beggiatoa,  molds,  yeasts. 

(b)  Characteristics  of  form:  long,  short,  straight, 
curved,  dimensions  in  microns,  square  or  round  ends,  oval, 
diplococci-like,  dumbbell-like,  clavate,  cuneate,  capsulated, 
non-capsulated,  growing  in  chains,  growing  in  masses,  fila- 
mentous, hyphae-like,  septate  or  non-septate. 

(c)  Sporulation:  equatorial,  polar,  bipolar,  chlamydo- 
spore  type,  conidia-like,  stained  or  unstained,  round  or 
oval,  discrete  or  in  masses,  the  size  of  the  spores  in  microns. 

(d)  Staining:  Gram  positive  or  negative,  lightly  or 
intensely,  evenly,  granularly,  punctately,  irregularly,  sec- 
tionally. 

(e)  The  growth :  luxuriant  or  scanty. 

To  avoid  illness  among  the  laboratory  assistants,  the  usual 
safeguards  against  infection  should  be  thoroughly  enforced, 
as  many  feces  contain  organisms  that  are  pathogenic  in  a 
greater  or  less  degree.  Bichloride  or  carbolic  solutions 
should  be  constantly  at  hand  and  great  care  in  the  use  of 
laboratory  towels  and  utensils  should  be  taken.  In  the  case 
of  the  incubator,  a  ventilating  tube  leading  to  the  chimney 
is  a  great  convenience,  especially  if  the  laboratory  is  in  imme- 
diate connection  with  other  rooms,  and  should  be  supplied 
when  possible. 


CHAPTER  IV 

THE  EXAMINATION  OF  URINE 


The  study  of  the  urine  in  enterocoHtis  gives  much  valu- 
able information.  When  properly  and  carefully  performed 
a  diagnosis  can  be  made  in  many  instances  by  this  means 
alone,  but  much  better  results  will  be  obtained  if  the  urinalyses 
and  the  fecal  examinations  are  compared  and  the  findings 
in  each  carefully  verified. 

The  customary  routine  examination  of  the  urine  is  first 
completed  and  recorded  in  the  patient's  history.  This 
investigation  includes  the  color,  the  odor,  the  cloudiness, 
the  specific  gravity,  the  amount  of  albumen  or  its  absence, 
a  quantitative  estimation  of  the  reduction  of  Fehling's  solu- 
tion, the  amount  of  chlorides  and  phosphates,  the  reaction 
to  litmus  and  microscopically,  a  thorough  search  for  casts, 
epithelium,  pus  and  crystals. 

The  chemical  bodies  that  will  be  hereafter  referred  to  as 
the  indices  of  intestinal  putrefaction  are  next  taken  up  in 
order.     At  the  present  writing  they  are  classed  as  follows: 

Indican  blue, 
Indican  red. 
Acetone, 
Diacetic  acid. 
Oxalic  acid, 
Uric  acid, 
Ammonia, 

The  body  responding  to  dimethylaminobenzalde- 
hyde. 

The  following  test  for  indoxyl  has  proven  the  most  con- 
venient and  reliable.  The  reagents  required  are  chem- 
ically pure  strong  hydrochloric  acid,  a  0.5  per  cent  solution 
of    potassium    permanganate    and    chloroform.     The    appa- 


26  THE  EXAMINATION  OF  URINE 

ratus  required  is  very  simple — a  25  c.c.  glass-stoppered  grad- 
uated cylinder  and  a  1  c.c.  pipette.  The  cylinder  is  first 
filled  to  the  5  c.c.  mark  with  urine,  then  to  the  10  c.c.  mark 
with  hydrochloric  acid  and  Ic.c.  of  chloroform  added  by 
means  of  the  pipette.  The  potassium  permanganate  should 
be  added  a  drop  at  a  time  and  the  tube  well  shaken  between 
each  addition,  until  upon  standing  the  chloroform  ceases 
to  grow  darker  in  shade.  The  two  most  frequent  errors  to 
be  guarded  against  are  the  too  rapid  addition  of  the 
reducing  agent,  i.e.,  the  permanganate  solution,  and  insuffi- 
cient shaking.  The  depth  of  the  blue  or  red  color  of  the 
chloroform  is  compared  with  that  of  the  color-scale  and  the 
result  recorded.  In  urines  showing  the  mixed  types  the 
proportions  of  blue  and  red  are  estimated  in  comparison 
with  the  scales. 

For  the  sake  of  the  accuracy  of  this  test,  as  well  as  in  the 
case  of  any  other  of  the  tests  for  the  putrefactive  indices,  all 
administration  of  medicinal  agents  should  be  suspended  for 
at  least  twenty-four  hours  before  the  urine  is  taken. 

The  presence  of  acetone  is  determined  by  Lieben's  or  by 
Gunning's  test.  If  the  patient  has  not  taken  alcohol  the 
former  is  preferred.  The  urine  should  be  as  fresh  as  possible 
and  the  amount  taken  for  testing  is  50 c.c.  An  Erlenmeyer 
flask,  fitted  with  a  rubber  cork  and  a  bent  glass  tube  of  proper 
length  to  reach  within  a  centimetre  or  so  of  the  bottom  of 
a  test  tube  surrounded  by  cold  water,  is  used  for  distillation. 
The  process  must  not  be  carried  on  too  rapidly.  The  dis- 
tillate is  then  treated  with  a  drop  or  so  of  Lugol's  solution 
and  decinormal  sodium  hydrate  solution  added  until  the 
color  of  the  iodine  has  been  discharged.  The  strength  of 
the  reaction  is  expressed  in  plus  marks,  thus:  +  0000  repre- 
sents a  trace  or  a  slight  odor  of  iodoform  upon  heating  the 
mixture,  ->-+  000  an  abundance  of  crystals  when  examined 
microscopically  yet  not  visible  to  the  naked  eye,  +  +  +  00  a 
visible  precipitate,  ++  +  +  0  a  considerable  precipitate, 
and  finally  +  +  +  +  +  a  reaction  so  strong  as  to  produce 
an  immediate  cloudiness  upon  adding  the  sodium  hydrate 
solution. 


THE  EXAMINATION  OF  URINE  27 

If  greater  accuracy  is  desired,  by  slow  distillation,  using 
ice  water  in  the  condenser,  collecting  the  iodoform  on  a  fil- 
ter, washing  first  with  very  dilute  hydrochloric  acid  and 
then  with  distilled  water,  and  finally  weighing  with  the  ana- 
lytical balance,  the  results  may  be  expressed  in  milligrammes 
of  iodoform  per  lOOc.c.of  urine,  and  this  figure  used  in  judg- 
ing the  progress  of  the  illness. 

If  Gunning's  test  is  used  the  tube  should  never  be  heated 
until  the  black  precipitate  of  nitrogen  iodide  has  entirely 
disappeared. 

The  Gerhardt's  or  Bordeau  red  reaction  is  used  in  test- 
ing for  diacetic  acid.  It  is  absolutely  necessary  that  the 
urine  be  perfectly  fresh.  In  moderately  cool  weather,  if 
the  morning  urine  can  be  examined  before  noon  of  the  same 
day,  the  test  may  be  depended  upon  for  accuracy,  but  during 
the  summer  months  it  is  much  safer  to  have  the  patient  pass 
urine  in  the  office  and  the  examination  made  immediately. 
All  medicines  should  be  omitted  for  twenty-four  hours  before 
the  urine  to  be  tested  is  taken.  The  strength  of  the  reac- 
tion is  recorded  in  plus  marks,  with  a  statement  of  the  char- 
acter of  the  reaction.  If  the  test  is  negative  the  symbol  00000 
is  used;  if  a  light  brown  shade  is  obtained  Bn  +  0000;  darker 
shades  of  brown  are  expressed  by  extra  plus  marks  as  in  the 
case  of  the  test  for  acetone.  If  the  test  gives  absolutely  no 
red  shade,  the  symbol  By 00000  is  added,  while  extra  plus 
symbols  are  added  to  express  reactions  of  increasing  inten- 
sity until  the  deepest  Burgundy  reactions  are  recorded  as 
By  +  +  +  +  +.  An  admixture  of  the  two  colors  may  also 
be  recorded  by  these  fomulae  if  desired;  for  example,  Bn  +  + 
000  By +0000  would  mean  a  moderately  light  brown  reaction 
showing  a  faint  red  tint.  If  the  precipitate  of  ferric  phos- 
phate obscures  the  test  it  may  be  removed  by  filtration. 

The  brown  shades,  outside  of  the  question  of  the  presence 
of  diacetic  acid,  are  also  valuable  in  the  estimation  of  the 
amount  of  organic  acids  and  acid  salts  excreted  by  the  kid- 
neys. 

Oxalic  acid  always  occurs  as  calcium  oxalate  when  present 
in  the  urine.     After  centrifuging  and  examining  under  the 


28  '  THE  EXAMINATION  OF  URINE 

microscope,  the  number  of  crystals  of  this  compound  may 
be  expressed  as  few,  numerous,  abundant  or  extremely  abun- 
dant, as  the  case  may  be. 

Their  abundance,  however,  may  be  much  better  expressed  in 
the  number  per  cubic  millimetre  of  urine  times  the  average 
diameter  in  microns  of  the  bases  of  the  crystals. 

The  presence  of  uric  acid  crystals  is  always  noted  in  the 
record  of  the  urinalysis,  but  as  a  general  thing  the  quantita- 
tive estimation  of  the  amount  of  this  acid  is  not  carried  out. 

The  presence  of  ammonium-magnesium  phosphate  crys- 
tals in  any  abundance  usually  means  that  a  putrefactive 
process  with  the  production  of  ammonia  is  present  in  the 
intestinal  canal.  The  source  of  this  ammonia  should 
always  be  confirmed  by  comparison  with  the  fecal  analysis. 
If  the  latter  shows  the  reaction  for  free  ammonia  or  the  pres- 
ence of  triple  phosphate  crystals,  the  ammoniacal  type  of 
putrefaction  may  be  diagnosed. 

The  test  with  dimethylaminobenzaldehyde  is  of  great 
value.  There  are  two  methods  of  recording  this  test — by 
the  use  of  the  color  scale,  and  by  titration.  In  both  methods 
the  following  formula  is  used: 

Ehrllch's  Aldehyde  Solution,  No.  1. 
Para-dimethylaminobenzaldehyde  15  grammes. 

10%  Solution  sulphuric  acid  300  c.c. 

This  gives  a  clear,  amber-colored  solution,  which  upon  stand- 
ing takes  on  a  greenish  tint  and  upon  boiling  has  an  aromatic 
odor  reminding  one  of  new-mown  hay.  This  solution  im- 
proves with  age. 

To  perform  the  test,  five  cubic  centimetres  of  the  urine 
are  brought  to  the  boiling  point  and  the  solution  added  drop 
by  drop  until  no  further  deepening  of  the  red  tint  can  be 
obtained.  While  the  mixture  is  still  hot,  the  shade  is  com- 
pared with  the  color  scale  and  the  result  recorded.  A  mod- 
ification of  the  ordinary  hemoglobinometer  may  also  be  used. 
In  either  case  the  strength  of  the  reaction  will  be  expressed  in 
a  percentage  based  upon  the  color  scale  used  in  estimation 
of  the  hemoglobin  in  the  blood.     The  depth  of  the  color  may 


THE  EXAMINATION  OF  URINE  29 

also  be  recorded  in  plus  marks,  00000  representing  an  ab- 
sence of  any  reaction,  +  +  +  +  +  the  deepest  red  tints  and 
the  intermediate  shades  by  combinations  of  the  two  symbols. 

The  use  of  color  scales  in  the  laboratory  is  hedged  about 
with  inaccuracy,  and  it  has  been  found  that  the  titration 
method,  especially  in  instances  where  this  test  has  been  used 
in  checking  the  dietary  of  the  patient,  gives  much  more 
uniform  results. 

The  apparatus  required  for  the  proper  performance  of 
this  operation  consists  of  a  one  cubic  centimetre  pipette 
graduated  in  0.01  c.c,  a  roller  pinch-cock  with  rubber  tubing, 
a  10  c.c.  graduated  cylinder,  test  tubes  and  Bunsen  burner. 
There  is  nothing  especially  novel  about  this  apparatus  except- 
ing the  roller  pinch-cock,  and  upon  the  smoothness  of  the 
operation  of  the  latter  the  success  or  failure  of  the  test  will 
in  a  great  measure  depend.  This  consists  of  two  metal 
rollers  and  the  containing  frame.  The  rollers  are  1.5  centi- 
metres in  diameter  and  2  centimetres  on  the  face.  The  sur- 
face of  the  first  roller  is  scored  parallel  to  its  axis'  with  a  hack- 
saw, in  order  that  the  rubber  tubing  that  is  to  pass  between 
them  may  not  slip.  The  scorings  have  a  depth  of  0.5  milli- 
metres and  are  spaced  1  millimetre  from  edge  to  edge.  A 
knurled  wheel  is  fitted  to  the  shaft  of  this  roller  and  the  outer 
edge  of  this  wheel  is  supplied  with  a  small  crank  handle.  The 
second  roller  is  left  smooth  and  revolves  on  a  shaft  constructed 
to  engage  the  yoke  mentioned  below.  The  frame  is  con- 
structed of  2  millimetre  flat  stock,  enough  length  being  allowed 
for  securing  the  apparatus  firmly  to  its  support,  bored  and 
slotted  so  that  the  scored  roller  and  knurled  head  has  a  good 
running  fit,  and  the  smooth  roller  may  be  brought  towards  or 
away  from  its  companion  as  may  be  required  in  the  adjustment 
of  the  apparatus.  A  yoke  and  adjustment  screw  is  then  fitted 
to  impart  motion  to  the  shaft  of  the  smooth  roller  in  such  a 
manner  that  the  surfaces  of  both  rollers  will  always  remain 
parallel.  With  rubber  tubing  of  proper  length  any  pipette 
may  be  operated  with  this  device  and  it  has  been  found 
very  convenient  in  measuring  infected  solutions. 


30  THE  EXAMINATION  OF  URINE 

The  following  formula  is  used  in  making  this  determination: 

Ehrlich's  Aldehyde  Solution  No.  2. 
Aldehyde  solution  No.  1  10  c.c. 

Distilled  water  90  c.c. 

Five  cubic  centimetres  of  this  solution  are  raised  to  boiling 
temperature  in  a  test  tube.  When  the  surface  of  this  solu- 
tion is  observed  at  an  angle  of  45°,  the  base  of  the  tube  rest- 
ing on  a  white  surface,  a  delicate  green  color  will  be  noted. 
If  this  color  is  not  present,  or  if  a  red  tint  is  noted  before  the 
addition  of  the  urine,  some  of  the  utensils  are  not  clean  and 
the  operation  should  be  repeated  with  fresh  solution.  The 
pipette  is  then  filled  to  the  zero  line  with  the  urine  under 
examination  and  any  excess  of  urine  removed  from  its  tip 
with  blotting  paper.  The  solution  is  kept  at  the  boiling 
point  during  the  titration  and  urine  added  drop  by  drop  until 
the  surface  of  the  mixture  when  observed  at  an  angle  af  45° 
assumes  a  delicate  pink  shade.  The  amount  of  urine  used 
multiplied  by  two  is  the  value  usually  used  in  expressing  the 
strength  of  the  reaction.  This  figure,  of  course,  is  inversely 
proportionate. 

The  matter  of  the  dimethylaminobenzaldehyde  reaction 
in  both  urine  and  feces  has  been  under  discussion  for  the  past 
fourteen  years  without  arriving  at  any  definite  conclusions. 
Skatol,  urobilogen  and  glycosamin  have  by  various  authori- 
ties been  mentioned  as  the  bodies  responsible  for  this  reaction. 
Professor  Herter  first  noted  that  the  urines  from  individuals 
suffering  from  the  most  excessive  intestinal  putrefactions 
were  especially  liable  to  give  the  most  pronounced  reactions. 
Among  my  own  patients  I  have  learned  to  associate  this 
reaction  with  severe  constitutional  symptoms  and  to  regard 
a  lessening  of  its  strength  a  most  favorable  sign,  an  increase, 
as  foreboding  disaster. 

The  color  of  the  urine  has  little  influence  upon  the  strength 
of  this  reaction.  As  many  dark  urines  give  a  very  delicate 
reaction,  while  in  others  of  a  pale  straw  tint  it  is  very  well 
marked,  apparently  the  urinary  pigments  cannot  be  held 
responsible. 


THE  EXAMINATION  OF  URINE  31 

Urines  that  gave  a  reaction  of  0.10  and  that  were  kept  in 
the  light  and  shaken  frequently  did  not  give  any  increase  in 
its  strength.  Others  were  extracted  with  ether  to  remove 
urobilogen  and  both  the  ether  and  the  residual  urine  tested. 
The  aldehyde  value  of  the  urine  remained  unchanged.  The 
ethereal  extract,  evaporated  to  dryness  and  dissolved  in 
alcohol,  was  negative. 

The  question  of  the  protein  split  products  was  taken  up 
as  a  possible  source  of  this  reaction.  Egg  white  was  pre- 
cipitated by  95%  alcohol,  filtered,  the  filter  washed  thor- 
oughly with  ether,  dried  and  powdered.  This  was  digested 
in  two  per  cent  sodium  hydrate  absolute  alcohol,  after  the 
method  of  Vaughn,  and  both  the  alcohol  and  the  solid  remain- 
ing portion  tested  with  aldehyde.  The  alcoholic  extract  was 
positive.  The  solid  portion  took  on  a  pink  shade  when  exam- 
ined by  light  reflected  from  the  surface  of  the  particles,  while 
by  transmitted  light  they  were  a  delicate  gray.  Specimens 
of  the  untreated  egg  white  were  negative  to  aldehyde. 

In  the  case  of  dessicated  thyroid  gland  the  soluble  portion 
was  negative,  the  insoluble  portion  gave  a  dark  red  reaction. 

The  sugars  were  uniformly  negative. 

Cultures  of  mixed  fecal  bacteria  were  positive.  Broths 
when  freshly  prepared  were  negative.  When  putrefaction 
had  begun  they  showed  a  marked  reaction  to  aldehyde. 

Witt's  peptone  was  positive,  as  well  as  other  beef  prepara- 
tions, advertised  as  "predigested."  Blood  was  negative, 
the  scales  from  psoriasis  were  negative.  Specimens  of  Witt's 
peptone  were  extracted  with  absolute  alcohol,  filtered  and 
dried.  The  filter  was  positive,  the  filtrate  was  negative  to 
aldehyde.     Typhoid    bacterins    were    negative. 

Fluid  extract  of  ergot  was  positive.  Vaughn  has  called 
attention  to  the  presence  of  certain  protein  split  products  in 
claviceps  purpurea,  so  this  reaction  was  not  surprising. 

Ergo  toxin,  a  trade  name  given  to  an  ergot  derivative,  gave 
a  positive  time  reaction.  Upon  first  adding  the  aldehyde 
solution  no  change  in  color  was  noted  upon  boiling.  After 
standing  a  few  minutes  the  mixture  changed  to  a  pronounced 
purple  color,  which  deepened  with  further  boiling. 


32  THE  EXAMINATION  OF  URINE 

A  specimen  of  ernutin,  another  ergot  derivative,  gave  the 
same  reaction  as  ergo  toxin. 

When  ernutin  was  treated  with  boiling  ten  per  cent  H2SO4 
and  allowed  to  stand  twenty-four  hours  the  reaction  with 
aldehyde   in   the   hot  was   very  sharp  and   distinct. 

Specimens  of  ergamin,  said  to  be  Beta-iminazolylethylamin, 
were  negative.  When  digested  with  ten  per  cent  HaSO'*  for 
several  days  this  drug  was  still  negative. 

Specimens  of  pancreatic  gland  substance,  combined  with 
bile  salts  were  slightly  positive. 

Fel  bovis  was  negative. 

Various  preparations  containing  bile  salts  were  negative. 

It  was  noted  that  during  the  titration  of  the  aldehyde 
solution  that  at  the  instant  the  change  in  color  took  place, 
there  was  also  an  ebullition  of  some  gas,  probably  hydrogen. 

Noting  the  fact  that  this  reaction  depended  upon  a  change 
in  color  of  the  reagent  from  green  to  red,  and  that  this  appar- 
ently took  place  through  an  increase  in  the  size  of  the  mole- 
cule of  the  aldehyde,  the  question  of  oxidation  came  to  mind. 
The  aldehyde  solution  was  consequently  tested  for  response 
to  oxidizing  compounds.  Hydrogen  peroxide  even  in  very 
weak  solutions  gave  a  marked  positive  reaction.  Magnesium 
peroxide  also  gave  a  very  strong  positive  reaction.  Potas- 
sium chlorate,  potassium  permanganate,  nitric  acid,  bismuth 
subnitrate  and  zinc  oxide  were  negative.  Fuming  nitric 
acid  (nitrous  acid)  in  the  cold  produced  a  yellow  reaction 
with  the  escape  of  gas;  upon  heating,  the  mixture 
grew  darker    and   finally    assumed   a  reddish  brown    color. 

Two  forms  of  fecal  fields  are  regularly  found  in  patients 
whose  urine  and  feces  give  a  marked  reaction  to  aldehyde. 
The  first  shows  a  very  luxuriant  growth  of  short,  plump, 
round  end.  Gram  negative  rods,  which  are  probably  the 
bacillus  of  Mellanby  and  Twort.  In  the  second  these  bacilli 
are  absent  and  in  their  place  hyphae  and  conidia  are  found 
in  abundnace.  The  bacilli  probably  produce  in  their  growth 
a  near  chemical  neighbor  of  beta-iminazolylethylamin  that 
is  responsible  for  this  reaction;  and  cultures  from  such  feces 
are  also  strongly  positive  to  aldehyde.     In  the  case  of  the 


THE  EXAMINATION  OF  URINE  33 

molds  the  evidence  pointing  to  the  production  of  fi-i  is  not 
so  clear.  In  view  of  the  fact  that  the  response  of  aldehyde 
to  oxidizing  agents,  even  in  minute  amounts,  is  especially 
prompt,  the  presence  of  an  oxidase,  the  result  of  the  bio- 
logical activity  of  intestinal  molds,  may  possibly  account 
for  this  reaction  in  case  the  bacilli  are  absent  from  the  fecal 
fields. 

If  the  liver  is  efficient  this  body  will  not  appear  in  the  urine 
in  an  amount  proportionate  to  its  abundance  in  the  feces. 
It  will  be  reduced  in  its  passage  through  that  organ  to  such 
an  extent  as  to  no  longer  respond  to  aldehyde. 

Judging  from  urinalyses  in  subjects  undergoing  typhoid 
immunization,  this  reaction  does  not  appear  in  the  urine 
during  the  course  of  parenteral  protein  digestion,  at  least  in 
normal  individuals. 

In  the  urine  of  sufferers  from  epilepsy  the  response  to 
aldehyde  is  remarkably  strong  and  more  especially  so  when 
an  attack  is  imminent.  The  presence  of  a  value  as  low  as 
0.05  is  generally  followed  by  a  convulsion  within  twenty-four 
hours. 

The  test  for  urobilin  is  useful  in  estimating  the  amount 
of  the  destruction  of  erythrocytes  that  is  taking  place.  Schles- 
inger's  method  will  be  found  the  most  convenient.  The 
following    reagents    are    required: 

1.  Zinc  Acetate  Alcohol. 
Absolute  alcohol  100  c.c. 
Zinc  acetate  to  saturation. 

2.  Lugol's  Solution. 

To  the  unfiltered  urine  an  equal  amount  of  the  zinc  acetate 
alcohol  is  added.  This  is  shaken  and  a  few  drops  of  Lugol's 
solution  added.  The  mixture  is  then  filtered  and  the  degree 
of  fluorescence  of  the  filtrate  recorded  in  plus  marks. 


CHAPTER  V 

THE  INDOLIC  TYPE  OF  INTESTINAL 
PUTREFACTION 


In  this  type,  the  onset  of  the  primary  stage  may  be  very 
acute  with  a  diagnosis  varying  frqm  enteric  grippe  to  para- 
typhoid fever. 

In  children,  we  often  meet  with  attacks  of  fever  lasting 
from  a  few  days  to  several  weeks,  in  which  the  urine  gives 
a  very  strong  reaction  for  indican.  The  sera  of  these  children 
do  not  agglutinate  the  typhoid  bacillus.  This  is  usually 
the  beginning  of  an  enterocolitis  with  this  type  of  intestinal 
putrefaction  and  the  gravity  of  this  condition  is  not  given 
the  attention  it  deserves.  This  type  often  develops  in  the 
course  of  a  chronic  enterocolitis,  which  in  the  beginning 
showed  another  type  of  putrefaction. 

Infection  in  these  cases  may  take  place  in  two  ways: 
by  way  of  the  mouth  through  the  agency  of  those  vegetables 
which  are  grown  in  intimate  contact  with  the  soil,  such  as 
radishes,  lettuce  and  celery,  by  contact,  either  direct  or 
indirect,  with  sources  of  infection  in  street  dust,  water  closets, 
door  handles  and  car  straps;  or  by  infections  extending  up- 
ward from  the  colon.  In  the  latter  form  of  infection,  which 
may  be  called  the  ascending  form,  insufficiency  of  the  intes- 
tinal valves,  certain  ptoses  of  the  intestines  or  a  weakness 
of  peristalsis,  facilitating  the  progress  of  bacteria  from 
one  portion  of  the  intestine  to  another,  may  be  assumed. 

Certain  families  seem  to  have  a  special  lack  of  resistance 
of  the  intestines  against  this  form  of  bacterial  invasion. 

The  symptoms  of  this  condition  may  be  considered,  accord- 
ing to  the  various  stages,  viz.  the  primary  stage,  if  such 
exists;  the  secondary  stage  and  the  tertiary  stage. 

The  symptoms  in  the  primary  stage  may  range  in  severity 


THE  INDOLIC  TYPE  35 

from  those  causing  little  trouble,  such  as  suddenly  develop- 
ing headaches  and  mild  abdominal  symptoms,  to  severe 
febrile  attacks,  confining  the  patient  to  bed  with  high  temper- 
ature. These  symptoms  may  last  from  three  days  to  two 
weeks,  often  giving  a  clinical  picture  which  strongly  resembles 
a  mild  typhoid  infection.  The  true  nature  of  these  symp- 
toms is  apt  to  be  overlooked,  but  an  examination  of  the  urine 
will  show  the  presence  of  indican  in  greater  or  less  amounts. 

In  the  secondary  stage,  the  symptoms  are  not  generally 
constant.  Attacks  of  dyspepsia,  so-called  indigestion, 
epigastric  pressure  or  distress,  lasting  for  a  fortnight  per- 
haps with  a  remission  of  about  a  month  and  then  a  return  of 
symptoms,  is  a  suspicious  syndrome.  In  this  stage  the 
symptoms  are  confined  to  the  abdominal  organs  and  are 
described  as  distress  or  discomfort,  burning,  pyrosis,  with 
or  without  constipation  or  diarrhoea.  These  are  laid  at  the 
door  of  indigestion  or  dyspepsia,  nervous  being  a  most 
favorite  prefix.  As  a  collateral  diagnosis,  the  patient  may 
add  chronic  appendicitis,  chronic  cholecystitis  and  intes- 
tinal indigestion  to  the  list  of  his  complaints.  Obscure  dis- 
turbances of  nutrition  and  metabolism  are  at  times  prominent. 

The  tongue  is  very  generally  coated,  especially  in  the 
morning,  and  the  breath  has  a  fecal  odor.  For  the  relief 
of  this  the  patients  resort  to  habitual  catharsis  very  early 
in  this  stage.  While  cathartics  give  a  marked  temporary 
relief  in  this  type,  no  permanent  improvement  is  ever  noted 
from  their  use. 

The  circulatory  system  shows  functional  disturbances  very 
early  in  this  stage  and  in  many  instances  the  patient  believes 
that  he  is  the  victim  of  some  severe  and  fatal  cardiac  dis- 
order. Palpitation,  tachycardia,  fainting  spells  and  dysp- 
noea  are    frequent   complaints. 

The  nervous  system  is  also  the  seat  of  many  functional 
disturbances  and  such  disorders  as  headache,  either  fre- 
quent or  habitual,  insomnia,  vertigo,  neurasthenia  are  very 
apt  to  be  present.  Migraine,  however,  is  rare  in  this  type 
of  putrefaction  and  its  presence  always  leads  one  to  suspect 
some  of  the  more  severe  acid  types  as  its  cause. 


36  THE  INDOLIC  TYPE 

The  specialized  organs,  the  eye,  the  ear  and  the  genital 
system  may  also  show  some  disturbance  of  function.  Many 
of  these  patients  complain  of  impotence  or  sterility  and  it  is 
interesting  to  note  that,  in  common  with  the  other  forms  of 
chronic  infection,  the  birth  rate  among  these  sufferers  is  low 
and  the  offspring  of  poor  vitality. 

These  patients  usually  pass  the  secondary  stage  in  an 
anemic  condition.  Their  strength  is  poor  and  even  if  there 
is  no  complaint  of  its  loss,  still  their  endurance  is  very  unsatis- 
factory, both  for  physical  and  mental  work. 

In  this  stage  the  physical  examination  shows  little  of  mo- 
ment. The  liver  is  neither  larger  nor  smaller  than  normal ;  the 
stomach  is  normal  to  palpation.  The  colon  may  be  dis- 
tended but  not  tender.  The  position  of  the  abdominal 
viscera  will  correspond  to  the  patient's  habitus.  Physical 
signs  of  disease  in  other  organs  will  be  lacking.  These  in- 
dividuals, on  the  other  hand,  give  the  examining  physician 
the  impression  that  they  are  ill. 

The  stomach  contents  show  little  of  interest.  There  is 
usually,  however,  a  hyperchlorhydria  but  no  evidence  of 
organic  gastric  disease. 

The  urine,  in  the  secondary  stage,  will  show  no  evidence 
of  kidney  involvement.  The  strength  of  the  indoxyl  reaction, 
however,  will  give  very  valuable  information  concerning  the 
severity  of  the  intestinal  condition  that  is  slowly  but  surely 
undermining  the  patient's  health. 

The  gross  appearance  of  the  feces  is  usually  fairly  normal. 
They  may  be  formed,  soft  or  liquid,  their  condition  depend- 
ing upon  the  kind  and  amount  of  cathartics  the  patient  is 
using.  There  is  little  mucus;  no  gross  particles;  the  color 
is  dark;  the  odor  not  abnormal.  The  reaction  is  alkaline. 
With  Lugol's  solution  free  starch  is  absent,  muscle  fasciculi 
and  crystals  are  absent,  yeast  cells  are  few  in  number  and 
oval  in  type. 

It  is  in  the  preparations  stained  according  to  the  method 
of  Gram  that  we  find  the  most  valuable  information  con- 
cerning this  type  of  putrefaction.  Upon  the  first  glance 
through  the  microscope,  the  great  prominence  of  the  blue 


OF  INTESTINAL  PUTREFACTION  37 

or  Gram  positive  organisms  will  be  noted.  The  largest  of 
these  will  be  a  bacillus,  capsulated,  growing  end  to  end  in 
pairs.  This  will  be  recognized  as  the  bacterium  Welchii. 
These  are  not  usually  very  abundant  and  their  growth,  in 
the  milder  grades  of  this  type  of  putrefaction,  is  not  luxuriant. 
The  next  most  abundant  form  will  be  the  bacillus  bifidus — 
medium  sized,  irregularly  contoured  rods,  often  of  headlet 
form,  at  times  bifurcated.  The  bacillus  putrificus  is  absent 
unless  the  disease  has  been  in  progress  for  some  time.  Posi- 
tive micrococci  are  very  rarely  observed,  as  in  the  simple 
indolic  type  ulcerative  processes  are  rare.  An  occasional 
Clostridium  may  be  observed. 

In  the  negative  field  the  small  number  of  bacilli  of  the  colon 
type  will  be  noted.  In  the  lighter  grades  their  number  may 
be  considerable,  but  in  the  more  severe  putrefactions  they 
will  be  absent.  The  severity  of  the  catarrhal  process  may 
be  estimated  by  their  number — the  less  abundant  they  are 
the  more  severe  the  disease.  The  fine,  negative  bacilli  of 
the  liquefaciens  ilei  type  may  be  present  when  the  stools  are 
soft  in  consistency.  Short,  fat  rods  without  capsules  are 
usually  absent.  It  is  rare  to  find  hyphae  and  spores  except 
in  the  more  severe  grades  of  putrefaction  and  then  only 
when  the  disease  has  been  in  existence  for  some  years. 

The  preparations  stained  with  thionine  show  the  same 
micro-organisms  mentioned  above. 

The  iodine  field  is  generally  negative.  In  some  speci- 
mens, however,  a  few  Clostridia  may  be  noted. 

The  blood  shows  little  of  moment  in  the  average  patient. 
In  the  latter  part  of  the  secondary  stage,  the  Hb.  value  begins 
to  diminish  and  in  some  instances  the  number  of  red  cells 
are  reduced.  An  anemia  of  the  pernicious  type  places  the 
individual  in  the  tertiary  stage  of  the  disease.  The  fact 
must  be  borne  in  mind,  that  the  blood  may  be  the  point  of 
attack  of  this  toxinwithout  other  organs  showing  organic  lesions. 

The  secondary  stage  may  continue  for  fifteen  to  thirty 
years  without  greatly  impairing  the  patient's  capacity  for 
work.  The  sufferers  are  much  more  likely  to  regard  them- 
selves as   more   uncomfortable   than   sick. 


38  THE  INDOLIC  TYPE 

In  the  tertiary  stage  abdominal  symptoms,  per  se,  form 
a  very  unimportant  part  of  the  dinical  picture.  Consti- 
pation may  be  present  or  often  an  intermittent  diarrhoea 
The  symptoms  referred  to  the  intestinal  canal  are  not  so 
impressive  as  those  that  arise  from  organic  disease  of  the 
heart,  kidneys,  liver  or  other  organs  that  have  begun  to  find 
their  burden  too  great. 

Various  forms  of  muscle  and  joint  lesions  are  common 
in  the  tertiary  stage,  such  as  myositis,  osteoarthritis  and 
rheumatoid  arthritis  and  the  finger  joints  usually  are  the 
seat  of  calcareous  deposits. 

In  the  nervous  system  organic  lesions  are  met  with  of  various 
grades  of  severity,  leading  to  psychoses,  neuralgia,  low  grades 
of  paralysis  and  disturbances  of  function. 

In  certain  sufferers  from  this  tpye  of  putrefaction  a  con- 
dition develops  that  may  best  be  described  by  the  term  pre- 
senility.  Outside  of  a  low  grade  anemia,  great  depression 
and  loss  of  strength  and  endurance  they  show  very  few 
symptoms.  The  physical  examination  is  usually  negative, 
the  blood  pressure  normal  or  below  normal,  but  besides  a 
marked  indicanuria  little  can  be  found.  They  become  a 
burden  to  themselves  and  their  family  and  usually  die  from 
some  intercurrent  disease. 


CHAPTER  VI 

THE   SACCHAROBUTYRIC   TYPE   OF 
INTESTINAL  PUTREFACTION 


"This  form  of  intestinal  derangement  is  characterized  by 
a  chronic  putrefactive  process  (having  its  seat  mainly  in  the 
large  intestine  and  lower  ilium)  and  due  to  the  action  of  very 
large  numbers  of  strictly  anerobic  butyric-acid  producing 
bacteria,  capable  of  multiplying  by  means  of  spore  forma- 
tion."—(Herter.) 

The  onset  of  the  primary  stage  of  this  type  of  putrefaction 
is  more  generally  gradual  than  sudden.  There  are  patients, 
however,  who  date  their  trouble  from  some  acute  illness, 
although  the  presence  of  a  true  saccharobutyric  type  at 
that  time  cannot,  of  course,  be  determined. 

The  secondary  stage  is  of  long  duration.  There  is  not 
usually  a  very  marked  departure  from  a  condition  of  fair 
health,  but  the  patient's  most  frequent  complaint  is  one  of 
indigestion,  dyspepsia  or  of  other  symptoms  due  to  the 
irritation  resulting  from  the  presence  of  ammonium  butyrate 
in  the  intestinal  canal.  Constipation  is  usually  the  rule, 
but  often  a  diarrhoea  may  be  present,  which  in  some  instances 
may  prove  refractory  to  treatment.  Considerable  burning 
accompanies  this  acute  disturbance.  The  constipation 
will  follow  the  usual  course,  beginning  as  the  atonic 
type,  passing  into  the  spastic  stage,  but  rarely,  in 
uncomplicated  cases,  reaching  the  point  of  stercoraceous 
diarrhoea.  Often  the  amount  of  flatus  is  greatly  increased, 
the  composition  of  which  will  be  found  upon  analysis  to  be 
hydrogen  and  nitrogen.  The  flatus  is  usually  of  very  little 
odor,  the  aromatic  character  of  normal  human  feces  and 
flatus  will  be  absent.  Occasionally  a  mild  odor  of  old  cheese 
may  be  noted. 


40  THE  SACCHAROBUTYRIC  TYPE 

The  mouth  is  frequently  sore  and  the  tongue,  from  the 
tendency  of  the  superficial  epithelial  layer  to  exfoliate  rap- 
idly, is  usually  bright  red.  The  tongue  may  be  glazed  and 
its  surface  is  often  cracked.  In  very  severe  conditions  the 
skin  may  also  be  extremely  irritable,  especially  sensitive  to 
light  and  wind,  and  in  many  of  these  people  the  exposed  sur- 
faces of  the  body  are  in  a  constant  state  of  inflammation 
during  the  summer  months.  In  some  people  the  subcutane- 
ous and  the  submucous  tissue  is  liable  to  attacks  of  oedema 
of  very  severe  grade,  the  so-called  Quincke's  oedema,  and 
the  possibility  of  this  swelling  involving  the  glottis  must 
always  be  borne  in  mind.  The  muscular  system  is  often  the 
seat  of  rheumatic  pains  of  greater  or  less  severity. 

In  the  nervous  system,  outside  of  some  vertigo  or  head- 
ache, nothing  very  alarming  is  present. 

In  the  circulatory  systems  very  few  disturbances  are  found 
excepting  slight  irregularities  in  the  heart's  action  and  pal- 
pitation. 

If  the  liver  is  still  equal  to  its  task,  very  little  trouble  will 
be  noted  outside  of  the  intestines.  When  the  patient's  diet 
has  been  of  such  nature  as  to  encourage  this  type  of  putre- 
faction, acute  disturbances  will  result  with  an  increased 
production  of  butyric  acid.  The  liver  is  then  found  swollen 
and  often  tender  to  pressure. 

A  mild  grade  of  anemia  is  very  common. 

The  patients  often  complain  of  a  moderate  loss  of  strength, 
often  progressive,  and  their  endurance  is  generally  so  poor 
that  the  completion  of  the  day's  work  becomes  extremely 
burdensome. 

The  onset  of  the  tertiary  stage  is  not  violent,  gradually 
the  signs  and  symptoms  of  degeneration  in  few  or  many 
organs  make  their  appearance  and  the  patient  slowly  sinks 
under  the  burden  that  the  wreck  of  some  specialized  organ 
imposes. 

Examination  of  the  gastric  contents  usually  shows  very 
little  of  a  pathogenic  nature. 

It  is  in  the  examination  of  feces,  however,  that  the  most 
valuable  information  is  found. 


OF  INTESTINAL  PUTREFACTION  41 

Macroscopically  the  stools  may  be  of  large  or  small  calibre, 
the  color  varying  from  deep  brown  to  reddish  brown,  except 
at  times  of  diarrhoea,  when  they  approach  a  light  yellow  tint- 
They  often  contain  mucus. 

Stained  with  dilute  Lugol's  solution,  free  starch  is  occasion- 
ally found,  but  muscle  fasciculi  with  striae  are  uniformly 
absent.  Clostridia  may  be  abundant.  With  Gram's  stain 
the  abundance  of  positive  diplobacilli  and  biscuit-shaped 
bacilli  with  strongly  refracting  capsules  will  be  noted.  The 
smaller  bacilli,  often  headlet  in  type,  will  be  very  numerous 
and  the  large  and  small  filaments  will  be  absent.  Large, 
lemon-shaped  Clostridia  will  be  seen,  growing  in  groups  and 
sporulating.  In  the  negative  field  the  presence  or  absence  of 
the  colon  bacillus  and,  if  present,  their  numbers  will  give  very 
valuable  information  as  to  the  severity  of  the  infection  and 
the  length  of  its  standing.  The  greater  the  number  of  bac- 
teria of  the  colon  type  found  in  the  fecal  fields,  the  lighter 
and  more  amenable  to  treatment  will  be  this  condition. 
The  presence  of  streptococci,  staphylococci  is  always  a  bad 
sign  and  denotes  the  presence  of  ulcerative  processes  in  the 
small  intestine  or  in  the  colon.  With  thionine  stain  most 
of  the  micro-organisms  will  take  a  violet  shade,  especially 
the  B.  Welchii.  Very  few  will  take  a  blue  shade  in  this  type 
of  putrefaction.  The  iodine  fields  will  generally  show  an 
abundance  of  the  Clostridia  of  Prazmowsky,  sporulating  and 
of  very  luxuriant  growth.  The  field  will  be  mildly  Gram 
positive  to  absolutely  positive  according  to  the  severity  of  the 
condition. 

The  urine  will  be  acid  and  usually  of  high  specific  gravity. 
Blue  indican  is  never  present  in  simple  cases,  although  in- 
dican  red  will  be  found  in  small  amounts.  Diacetic  acid  and 
acetone  are  uniformly  absent.  The  test  with  Ehrlich's  alde- 
hyde is  usually  negative.  In  the  tertiary  stage  albumen 
and  casts  often  make  their  appearnace;  in  the  primary  and 
secondary  stages,  the  urine  is  microscopically  negative. 

This  is  the  most  common  type  of  intestinal  putrefaction 
as  well  as  the  least  fatal.  The  duration  of  many  cases  must 
be  measured  in  decades,  not  in  years.     In  many  individuals 


42  THE  SACCHAROBUTYRIC  TYPE 

with  the  milder  grades  little  inconvenience  is  suffered.  They 
may  realize  that  they  have  a  liver,  that  certain  articles 
of  food  are  better  left  uneaten.  Their  general  health,  how- 
ever, is  not  markedly  impaired  and  they  often  attain  a  ripe 
old  age  and  die  from  some  intercurrent  disease  without  ever 
entering  the  tertiary  stage  of  enterocolitis  with  the  sac- 
charobutyric    type   of   intestinal    putrefaction. 

The  liver  is  the  organ  most  liable  to  attack.  Through 
years  of  overwork  in  oxidizing  the  acid  products  of  the  dis- 
ease a  cirrhosis  finally  develops.  This  in  turn,  through  the 
pressure  of  the  contracting  fibrous  tissue,  further  damages 
the  stroma  until  finally  the  patient  ends  his  days  on  a  milk 
diet.  This  type  is  especially  common  in  individuals  who 
have  overindulged  in  severe  physical  exercise,  such  as  the 
professional  football  player,  the  heavy  weight  lifter,  the  iron 
bar  bender,  and  others  who  earn  their  living  by  feats  of 
strength  and  have  thereby  injured  the  oxidizing  power  of 
their  liver.  In  such  individuals  the  probability  of  a  complete 
recovery  is  very  remote. 


CHAPTER  VII 

THE   ACETIC   TYPE   OF   INTESTINAL 
PUTREFACTION 


This  type  is  characterized  by  the  production  of  ^-oxy- 
butyric  acid,  diacetic  acid  and  acetone,  either  singly  or  in 
combination,  in  the  intestinal  canal. 

The  primary  stage  is  not  usually  marked  by  symptoms 
severe  enough  to  confine  the  patient  to  bed,  and  is  passed 
with  the  diagnosis  of  overwork,  in  need  of  a  tonic,  or  some 
of  the  terms  so  often  used  in  slipshod  diagnosis  is  applied  to 
it.  At  this  period  the  tongue  is  usually  coated,  some  abdom- 
inal distress  may  be  present  and  occasionally  constipation  or 
diarrhoea  of  mild  grade.  In  other  words,  the  patient  sud- 
denly finds  his  vitality  reduced  from  some  obscure  cause.  Re- 
covery  in    this   stage    may    be   spontaneous   and   complete. 

If  this  condition  advances  to  the  secondary  stage,  the 
patient  begins  to  notice  an  increasing  loss  of  strength  and 
vigor.  With  this  he  begins  to  develop  a  pallid  complexion, 
notices  that  his  tongue  is  habitually  coated,  finds  great  re- 
lief from  the  more  or  less  constant  use  of  cathartics,  but 
rarely  does  he  report  any  great  diminution  of  his  appetite. 
As  he  advances  in  this  stage  he  complains  more  and  more  of 
intense  thirst.  The  abdominal  symptoms  in  uncomplicated 
cases  are  usually  of  little  moment.  This  stage  may  run  on 
for  several  years  or  even  decades. 

The  tertiary  stage  may  come  like  a  thief  in  the  night  and 
the  individual  suddenly  awakens  to  the  fact  that  his  days  are 
numbered.  On  the  other  hand,  the  most  intense  abdominal 
symptoms  of  very  alarming  character  may  be  present.  Oc- 
casionally the  nervous  system  bears  the  brunt  of  the  attack, 
and  convulsive  seizures  or  a  comatose  condition  will  develop 
without  warning.     There  is  always  the  possibility  that,  in 


44  THE  ACETIC  TYPE 

the  latter  instance,  the  individual  may  die  without  regaining 
consciousness. 

Acetone  production  is  a  common  occurrence  in  persons  who 
consider  themselves  in  fair  bodily  health.  In  this  case, 
however,  we  may  assume  the  presence  of  a  mild  intestinal 
catarrh  that  has  so  reduced  the  strength  of  intestinal  anti- 
septic as  to  render  putrefaction  possible,  without  being  of 
sufficient  severity  to  cause  any  local  symptoms.  This  ace- 
tone production  may  be  either  continuous  or  intermittent, 
varying  in  severity  as  the  person's  intestinal  resistance  may 
vary  from  day  to  day,  or  with  the  character  and  condition 
of  the  food  ingested. 

The  anemias  accompanying  this  type  of  putrefaction  with 
the  production  of  acetone  alone  are  often  severe  and  the 
destruction  of  erythrocytes  very  marked. 

In  many  instances  acetone  may  be  present  in  the  circu- 
lation in  such  amounts  as  to  impart  a  pronounced  odor  to 
the  breath  without  any  marked  departure  from  fair  health. 

In  diacetic  acid,  however,  we  have  to  deal  with  a  much 
more  potent  poison.  Rarely  is  this  body  found  in  the  urine 
without  toxic  symptoms  referred  to  various  organs  of  the 
body  occupying  a  very  prominent  position  in  the  syndrome. 
The  liver  is  very  generally  the  first  to  feel  the  attack  of  this 
poison  and  is  found  swollen,  the  edge  round  and  firm  and 
usually  sensitive  to  pressure.  The  liver  may  be  regarded 
as  a  filter  placed  between  the  circulation  through  the  intes- 
tinal wall  and  the  general  blood  stream.  One  of  its  most 
important  functions  is  to  promptly  remove  any  acids  or  toxic 
bodies  from  the  blood  that  passes  through  it  and  to  hydrolyse 
them  into  simpler  and  less  irritating  chemical  bodies.  These 
poisonous  bodies,  unless  they  are  of  such  stable  composi- 
tion as  to  be  incapable  of  oxidation  in  the  animal  cells,  are, 
in  the  case  of  most  of  the  toxins  absorbed  from  the  intestinal 
contents,  reduced  to  carbon  dioxide  and  water.  This  chem- 
ical process  is  similar  to  that  which  takes  place  when  sarco- 
lactic  acid  is  washed  out  of  the  muscular  system  and  brought 
to  the  liver  for  disposal.  Therefore,  when  a  severe  acid  putre- 
faction is  present  in  the  intestinal  canal,  an  increased  excre- 


OF  INTESTINAL  PUTREFACTION  45 

tion  of  carbon  dioxid  is  present,  provided  a  requisite  amount 
of  oxygen  is  supplied  to  the  liver  cells.  While  the  liver  is 
equal  to  the  task,  the  constitutional  symptoms  are  few  in 
number  and  of  little  moment.  When,  however,  that  great 
biochemical  apparatus  begins  to  find  the  task  too  heavy, 
when  the  members  of  the  fatty  acid  series  begin  to  appear 
in  the  general  circulation  and  the  burden  of  oxidation  is 
thrown  upon  the  parenteral  and  parhepatic  cells,  then  the 
patient  first  realizes  that  there  is  a  marked  departure  from 
normal  conditions.  Strange  to  say,  he  rarely  complains  of 
symptoms  referred  to  the  seat  of  trouble;  on  the  contrary, 
it  is  the  heart,  the  nervous  system,  the  kidneys,  or  a  general 
feeling  of  weakness  that  first  attracts  his  attention. 

^-oxybutyric  acid  is  never  found  in  the  urine  unless  the 
function  of  the  liver  is  impaired  or  exhausted.  The  complete 
reduction  of  one  molecule  of  /9-oxybutyric  acid  requires  nine 
atoms  of  oxygen.     Thus: 

CH3-CHOH-CH2-COOH  +  9  O  =  4  CO2  +  4  H2O, 
in  the  case  of  acetone  eight  are  required: 

CH3-CO-CH3  +  8  O  =  3  CO2  +  3  H2O, 
while  with  diacetic  acid  eight  also  are  required: 

CH3-CO-CH2-COOH  +  8  O  =  4  CO2  +  3  H2O. 

The  molecule  of  /9-oxybutyric  acid  contains  four  carbon  atoms, 
that  of  diacetic  acid  four,  while  that  of  acetone  contains  but 
three.  The  hydrogen  content  is  eight,  six  and  six  in  order. 
The  difference  between  the  two  acid  bodies  lies  in  the  absence 
of  two  hydrogen  atoms  in  the  group  CHOH.  As  would  be 
expected  the  greater  toxicity  of  the  /3-oxybutyric  acid  is  the 
result  of  the  presence  of  the  two  extra  hydrogen  atoms  that 
it  contains.  It  does  not  seem  probable  that  the  liver  would 
waste  much  effort  in  reducing  diacetic  acid  to  acetone : 

CH3-CO-CH2-COOH  =  CH3-CO-CH3  +  CO2. 
diacetic  acid  acetone 

On  the  contrary,  the  following  chemical  equation  would  seem 
much  more  probable: 

CH3-CO-CH2-COOH  +  80  =  4CO2  +  3H2O. 


46  THE  ACETIC  TYPE 

Most  specimens  of  feces  from  subjects  showing  acetone  in 
the  urine  have  a  marked  odor  of  this  chemical  and  also  show 
an  abundance  of  bacteria  and  molds  that  are  known  to  pro- 
duce acetone  freely  in  their  growth.  Careful  study  of  the 
stools  in  diabetes  leads  to  the  conclusion  that  the  source  of 
/?-oxybutyric  acid,  diacetic  acid  and  acetone  is  not  the 
metabolic  activity  of  any  human  organ,  but,  on  the  contrary, 
that  they  are  the  direct  result  of  a  chronic  intestinal  putre- 
factive process. 

These  three  poisons  have  a  strongly  selective  action  upon 
the  islands  of  Langerhans  of  the  pancreas  and  the  tissue  in 
their  immediate  neighborhood.  From  the  observation  of 
individuals  suffering  from  diabetes  mellitus,  acetonemia  and 
kindred  diseases  the  conclusion  seems  logical  that  acetone 
and  diacetic  acid  were  formed  within  the  intestinal  canal  for 
years  before  the  glycosuria  developed;  that  the  pancreas 
never  felt  the  effects  of  these  toxins  until  the  liver  became 
incapable  of  guarding  the  general  body  parenchyma;  and 
that,  through  inflammation  or  destruction  of  the  tissue  of 
the  islands  of  Langerhans  the  production  of  pancreatic  sucrase 
was  finally  so  reduced  as  to  render  the  individual  unable  to 
utilize  his  own  glycogen.  This,  of  course,  in  diabetes  of  the 
pancreatic  type. 

In  most  sufferers  from  diabetic  conditions  it  is  a  compara- 
tively easy  matter  to  check  the  production  of  diacetic  acid 
and  acetone  in  the  intestines  for  a  time  at  least,  and  the  improve- 
ment shown  by  these  patients  is  often  remarkable.  The  reduc- 
tion of  the  amount  of  sugar  excreted,  however,  is  a  different 
problem.  Unfortunately  no  one  has  as  yet  been  able  to 
obtain  pancreatic  sucrase  either  synthetically  or  by  extraction. 
Until  this  is  done,  our  efforts  to  make  diabetic  patients  util- 
ize the  glycogen  that  every  day  is  returned  to  nature,  a  waste 
product  of  faulty  metabolism,  are  not  likely  to  meet  with 
much  success.  To  some  of  these  individuals,  however,  a 
ray  of  hope  may  be  extended.  There  is  the  possibility 
that  some  pancreatic  tissue,  handicapped  by  toxemia  or  by 
surrounding  inflammatory  disturbances,  may,  when  its  bur- 
den is  lifted,  regain  its  function.     In  this  instance  sucrase 


OF  INTESTINAL  PUTREFACTION  47 

may  be  elaborated  in  such  amounts  as  to  enable  the  individ- 
ual to  assimilate  carbohydrates  in  sufficient  quantity  to  sus- 
tain nutrition. 

In  consequence,  the  amount  of  sugar  found  in  the  urine  is 
not  of  so  great  importance  is  are  the  strength  of  the  putre- 
factive indices.  These  individuals  are  better  nourished  and 
have  much  greater  strength  and  endurance  if  considerable 
amounts  of  carbohydrates  are  allowed.  When  a  wound  or 
an  abrasion  becomes  accidentally  infected  in  the  course  of  the 
disease,  a  strict  starch  and  sugar-free  diet  may  be  put  in  force. 
It  has  often  appeared  from  the  study  of  surgical  lesions  in 
diabetes,  that  too  strict  a  diet  had  so  reduced  the  resistance 
of  the  patient  as  to  court  rather  than  to  prevent  infection. 

This  type  of  putrefaction  often  precedes  severe  degenera- 
tive processes  in  the  nervous  system.  Individuals  suffering 
from  various  psychoses,  epilepsy  and  retinitis  pigmentosa, 
often  show  this  type  in  a  marked  degree. 

The  feces,  when  acetone  alone  is  present,  may  be  either 
scybalous,  soft  or  liquid.  They  are  usually  dark  in  color* 
varying  from  brown  to  blackish  brown.  Mucus  is  usually 
normal  in  amount,  but  at  times  may  be  abundant.  The  odor 
is  aromatic,  often  intensely  so,  and  in  some  specimens  vinegar- 
like. The  reaction  to  litmus  may  be  acid  or  alkaline,  and  the 
blue  paper  moistened  with  water  and  suspended  in  the  con- 
taining vessel  will  often  show  the  presence  of  volatile  acid. 

Microscopically,  when  stained  with  dilute  Lugol's  solution, 
free  starch  is  generally  present  in  considerable  amounts, 
especially  if  potatoes  are  a  staple  article  of  diet.  Striated 
muscle  fasciculi  are  uniformly  absent. 

Gram  stained  preparations  show  an  abundance  of  large 
bacilli,  measuring  six  by  one  microns  or  thereabout,  with 
rounded  ends,  capsulated  and  growing  singly,  never  in 
chains,  always  positive  unless  degeneration  has  taken 
place,  and  never  unevenly  stained  nor  granular.  Spore 
formation  has  never  been  noted  in  feces.  The  next 
most  abundant  positive  micro-organism  is  the  bacillus 
bifidus — 3  to  5  by  0.2  to  0.4  microns,  irregular  in  form, 
unevenly    stained    at    times,    sometimes    bifurcated    or     of 


48  THE  ACETIC  TYPE 

headlet  form.  This  bacillus  bifidus  is  always  found  when 
acetic  acid  is  present  in  the  intestinal  contents.  Unless  the 
cell  body  is  undergoing  degeneration  it  is  always  Gram  posi- 
tive, although  some  bacilli  may  have  negative  sections,  giv- 
ing them  a  mottled  appearance.  Other  bacteria,  positive 
to  this  stain,  such  as  the  capsulatus  and  the  Clostridia  may  be 
present,  but  never  in  great  numbers,  nor  of  luxuriant  growth. 
Among  the  Gram  negative  forms,  the  bacillus  coli  will  be 
found  in  abundance  in  the  milder  types,  less  and  less  numer- 
ous as  the  severity  of  the  putrefactive  process  increases, 
finally  being  absent  in  the  most  severe  grades. 

In  preparations  stained  with  thionine  blue,  outside  of  a 
few  hyphae  and  conidia,  little  of  moment  will  be  noted. 

In  the  thick  films  when  strong  Lugol's  solution  is  used  as 
stain,  a  few  organisms  positive  to  iodine  may  be  found. 

When  in  addition  to  acetone,  diacetic  and  /3-oxybutyric 
acid  are  present,  the  evidences  of  disease  in  the  stools  are 
much  more  marked. 

Macroscopically  they  may  still  be  scybalous,  soft  or  liquid, 
but  mucus,  either  membranous,  glairy  or  blood  stained  is 
generally  a  prominent  feature.  Unless  there  is  a  marked 
ammoniacal  putrefaction  present  as  a  complicating  condi- 
tion, the  feces  are  extremely  acid  and  cause  considerable 
burning  in  their  passage  through  the  rectum.  The  odor  of 
these  stools  stands  alone  as  the  most  disgusting  encountered 
in  the  laboratory.  It  may  be  described  as  alcoholic, 
aromatic,  butyric,  acetic,  musty,  stinking  and  sickening, 
and  while  examining  these  stools  one  wonders  how  any 
patient  could  pass  such  feces  without  having  his  attention 
very  forcibly  called  to  the  condition  of  his  intestinal  canal. 

Examined  with  dilute  Lugol's  solution,  free  starch  is  usu- 
ally very  abundant,  Clostridia  and  iodine  positive  rods  of  large 
size  numerous  and  round  and  oval  yeast  cells  plentiful  and  of 
very  luxuriant  growth.  Striated  muscle  fasciculi  may  be 
present  if  the  patient's  health  has  been  much  affected,  if 
salted  meat  has  been  eaten  or  if  cathartics  are  habitually 
taken. 

The    Gram    positive     fields      are     especially     rich    and 


OF  INTESTINAL  PUTREFACTION  49 

will  contain  Clostridia,  large  round-end  rods,  granularly 
stained  fusiforms,  B.  bifidi  and  B.  Welchii  in  great  numbers. 
The  B.  putrificus  is  not  regularly  present.  The  negative 
field  is  also  very  rich  in  bacteria.  Large,  medium  and 
small  rods  will  be  abundant  and  large  hyphae-like  bodies 
often  containing  chlamydospores,  or  transparent  spores  occur- 
ring singly  or  in  masses  will  be  found  abundantly.  The  colon 
type  will  be  absent  or  only  sparingly  represented. 

It  is  in  the  smears  stained  with  strong  Lugol's  solution, 
however,  that  the  most  characteristic  pictures  of  this 
diacetic-/?-oxy-butyric  putrefaction  will  be  found.  The  rich- 
ness of  these  fields  in  iodine  positive  fungi  of  various  form  is 
remarkable.  Large  deeply  stained  rods  often  bearing  trans- 
parent subpolar  spores  and  lightly  colored  conidia  with  indis- 
tinct outline,  are  very  abundant.  The  spores  often  occur 
singly  or  in  masses  and  in  either  instance  their  capsules  take 
a  delicate  purple  color.  Clostridia  are  numerous,  usually 
sporulating  and  of  luxuriant  growth.  Masses  of  a  fusiform 
bacillus  will  be  found,  staining  delicately  with  iodine,  growing 
in  chains  and  containing  small  transparent  spores.  These 
chains  are  often  laid  side  by  side,  giving  the  effect  of  several 
strings  of  sausages  arranged  in  parallel  lines  and  in  close  con- 
tact. Smaller  bacilli  staining  delicately  and  sectionally  are 
numerous.  Granular  starchy  matter  and  much  bacterial 
detritus  staining  a  light  blue  will  be  abundant. 

The  yeasts,  more  especially  those  taking  the  round  form, 
are  very  abundant  in  all  microscopical  preparations.  They 
very  generally  contain  deeply  stained,  iodine  positive  granules'. 

The  carbol-thionine  stain  may  be  used  to  check  up  the 
general  microscopical  findings  and  in  the  search  for  the 
micrococci  of  suppuration  that  may  shed  some  light  upon  the 
severity  of  the  local  lesion  in  the  intestinal  canal. 

The  biochemical  process  going  on  in  the  intestinal  canal 
among  the  micro-organisms  gaining  a  parasitic  livelihood 
at  the  expense  of  their  host  presents  a  very  interesting  prob- 
lem. The  sugars  and  free  starches  are  first  hydrolysed  by 
the  hyphomycetes  (yeasts  and  molds)  partly  into  acids  of 
the   lower   carboxyl    series   and    partly    into   alcohols.     The 


50  THE  ACETIC  TYPE 

latter  are  still  further  attacked  by  a  class  of  mirco-organisms 
with  the  production  of  acetic  acid  and  its  near  chemical  neigh- 
bors. At  this  point  in  the  process,  members  of  the  bifidus 
group  change  these  acids  into  ketones,  leaving  behind  those 
they  are  unable  to  hydrolyse.  A  part  of  these  products  of 
bacterial  metabolism  is  discharged  with  the  feces.  Of  the 
part  absorbed,  the  ketones  are  excreted  by  the  kidneys  and 
the  lungs,  while  the  acids  are  oxidized  in  the  liver.  If  the 
latter  organ  is  unequal  to  the  task  imposed  upon  it,  while 
some  of  the  acids  may  be  oxidized  by  the  cells  of  the  general 
body  parenchyma,  the  major  portion  leaves  the  circulation 
through  the  kidneys. 

The  urine  in  this  type  of  putrefaction  will  show  a  marked 
reaction  for  acetone,  diacetic  acid  or  /3-oxybutyric  acid, 
either  singly  or  in  combination.  High  specific  gravities  are 
the  rule,  and  the  reaction  is  usually  strongly  acid.  If  the 
pancreas  has  been  attacked  sugar  is  usually  present.  Many 
of  the  urines  will  contain  albumen  and  casts  and  these  often 
disappear  if  improvement  is  gained  through  treatment. 

The  amount  of  damage  this  type  of  putrefaction  does  to 
mankind  is  remarkable.  Its  onset  is  insidious  and  often  its 
presence  is  never  suspected  until  symptoms  arising  from  the 
disturbance  of  the  functions  of  some  specialized  organ  leads 
to  an  investigation  of  the  patient's  general  condition.  Un- 
fortunately this  usually  comes  too  late.  It  is  common  among 
people  who  gain  their  living  through  severe  mental  labor,  or 
who  are  exposed  to  great  emotional  strains.  Certain  fam- 
ilies and  also  certain  races  are  especially  susceptible  to  its 
ravages.  Among  individuals  who  are  the  misguided  vic- 
tims of  vegetarianism,  and  who  find  a  great  financial  saving 
in  a  meat-free  diet,  this  disease  is  very  prevalent  and  fatal. 


CHAPTER  VIU 

THE   OXALIC   TYPE   OF   INTESTINAL 
PUTREFACTION 


There  are  certain  sufferers  from  enterocolitis  who  present 
a  most  peculiar  history.  The  primary  stage  usually  escapes 
notice,  although  it  may  be  severe  enough  to  confine  the  pa- 
tient to  bed.  In  the  latter  case,  intense  muscular  pains  re- 
quiring anodynes  for  their  relief,  weakness  and  disordered 
defecation,  with  or  without  a  discharge  of  mucus  per  anum, 
are  prominent  symptoms.  The  primary  stage  may  last  from 
a  few  days  to  a  week,  or  even  longer  and  the  importance  of 
the  attack,  as  the  beginning  of  a  long  siege  of  ill  health,  is 
not  realized  at  the  time. 

The  secondary  stage  is  ushered  in  with  a  period  of  fair 
bodily  comfort  of  some  length,  but  the  patient  notices  that 
his  strength  and  endurance  are  less  than  they  were  before  the 
primary  sickness.  Muscular  pains,  either  constant  or  inter- 
mittent, begin  to  increase  until  the  patient  is  rarely  free  from 
suffering.  This  condition  progresses  until  his  nights  are 
spent  in  futile  efforts  to  find  a  comfortable  position  in  which 
he  may  rest  without  pain  and  his  days  in  regaining,  through 
massage  and  exercise,  his  muscular  functions.  The  muscles 
are  not  swollen  but  are  at  times  extremely  tender  and  through 
disuse  become  flaccid.  This  flaccidity  leads  to  the  develop- 
ment of  acquired  enteroptosis,  flat  foot  and  other  myastheniae, 
which  add  their  burdens  to  those  the  patient  already  carries. 

The  abdominal  symptoms  are  usually  of  little  moment,  but 
in  many  of  the  cases,  the  intense  burning  and  tenesmus  at 
stool  and  immediately  afterward  will  upset  the  most  calm 
and  phlegmatic  disposition.  These  people  resort  to  cathar- 
tics very  early  in  the  disease  as  they  find  that  a  series  of 
diarrhoeal  discharges  have  a  very  beneficial  effect  upon  the 


52  THE  OXALIC  TYPE 

severity  of  the  muscular  pains.  This  free  catharsis,  so  far 
as  the  intestinal  condition  is  concerned,  only  adds  fuel  to  the 
-flame.  The  mucus  is  increased  remarkably  in  amount,  the 
stools  become  more  acrid  in  their  nature  and  a  very  bad 
matter  is  made  much  worse. 

There  are  many  infallible  remedies  for  this  so-called  rheu- 
matism in  the  market,  each  accompanied  by  a  guarantee  of 
sure  cure.  These  are  tried  in  turn,  the  drastic  cathartic 
effect  of  each  adding  its  quota  of  damage.  Various  irregular 
practitioners  will  probably  have  tried  their  methods  upon  the 
case  until,  thoroughly  steeped  in  their  persuasive  conversa- 
tion, the  patient  cannot  tell  whether  he  is  suffering  from  a 
displacement  of  the  tenth  rib  pressing  on  a  nerve,  or  an  ex- 
aggerated condition  of  sin  and  fear.  There  is  one  fact  very 
patent  to  him,  however,  and  that  is  that  he  is  growing  more 
inefficient  day  by  day,  while  to  outward  appearance  he  is 
enjoying  at  least  fair  health. 

In  another  class  of  patients  the  production  of  oxalic  acid 
and  oxalates  is  intermittent  or  cyclical.  Sudden  attacks  of 
very  acute  pain,  referred  to  the  liver,  kidneys  or  muscles, 
occur  periodically.  Under  the  rigid  diet  the  patient  enforces 
in  the  few  weeks  following  his  illness,  the  periods  of  remission 
are  passed  in  comparative  comfort.  There  will  be  very  few 
days,  however,  that  the  signs  of  this  type  of  putrefaction  can- 
not be  found  in  the  urine  and  feces.  As  time  effaces  the 
memory  of  the  former  attack  and  the  patient  uses  less  dis- 
cretion in  the  selection  of  his  food,  the  train  is  laid  for  another 
explosion.  This  course  may  continue  for  many  years  and  as 
the  importance  of  the  lesion  dependent  upon  foreign  micro- 
scopic crystalline  structures  in  the  body  parenchyma  does 
not  make  a  great  impression  upon  the  average  patient,  treat- 
ment is  very  seldom  continued.  Finally,  a  trace  of  albu- 
men found  by  some  insurance  examiner  or  a  hematuria  brings 
the  patient  to  the  realization  of  the  seriousness  of  his  illness. 

His  appetite  may  be  enormous,  with  an  especial  craving 
for  desserts  of  various  kinds.  He  may  proudly  tell  you,  on 
the  other  hand,  that  animal  food  could  not  account  for  his 
condition,  as  he  had  carefully  avoided  it  for  some  years. 


OF  INTESTINAL  PUTREFACTION  53 

These  are  the  most  important  symptoms  in  the  picture  of 
this  disease.  Other  organs  may  begin  to  show  disturbances 
of  function  without  demonstrable  organic  lesions. 

The  feces  may  be  either  formed,  soft  or  liquid,  may  or  may 
not  contain  much  mucus  and  are  usually  of  a  musty  odor. 
Chemically  they  may  be  acid  or  alkaline,  more  generally  the 
latter,  and  show  a  pronounced  reaction  with  Ehrlich's  alde- 
hyde. Microscopically,  free  starch  may  be  present  in  the 
more  severe  grades  and  absent  in  the  lighter  types.  Muscle 
fasciculi  are  generally  absent.  Among  the  crystalline  struc- 
tures those  of  calcium  oxalate  may  be  very  abundant,  but 
fatty  acid  crystals  will  be  very  few  in  number.  In  Gram 
stained  preparations  among  the  positive  micro-organisms 
many  rods  of  large  size  with  square  ends  having  a  positive 
line  across  each  end  and  one  along  the  side,  with  a  Gram  nega- 
tive cell  body  will  be  found  in  abundance.  Also  cuboid  spores, 
single-celled,  having  a  length  twice  their  diameter,  capsulated 
and  occurring  singly  will  be  abundant.  A  few  bacillus  of 
bacterium  Welchii  and  also  a  few  bacilli  bifidi  will  be  noted. 
The  Gram  negative  field  in  the  milder  grades  will  show  an 
abundance  of  bacillus  communis  coli. 

Urinalysis  will  show  no  evidence  of  renal  disease  in  the 
mild  cases;  in  the  more  severe  cases,  however,  an  albumen- 
uria,  which  is  usually  intermittent  will  often  be  noted.  The 
indices  of  intestinal  putrefactions  of  other  types  will  be  very 
weak  or  lacking,  but  the  amount  of  oxalate  of  lime,  found 
in  crystalline  form  in  the  sediment  of  the  urine  will  be  remark- 
able. 

In  the  tertiary  stage  casts,  either  hyaline,  granular  or 
bloody  may  be  abundant. 

If  the  feces  are  sown  on  glucose  agar,  at  the  end  of  several 
days  at  room  temperature,  a  fuzzy,  velvety  growth  will 
appear.  Stained  specimens  of  this  growth  will  regularly 
show  the  presence  of  monilia. 

The  tertiary  stage  may  begin  without  violent  symptoms. 
The  lesions  of  some  organ  important  to  metabolism  and 
excretion  at  the  onset  may  not  attract  attention.  On  the 
other  hand,  this  stage  may  begin  with  such  violence  as  to 


54  THE  OXALIC  TYPE 

lead  to  the  diagnosis  of  an  acute  lesion.  In  this  connection 
the  estimate  that  ninety  per  cent  of  cases  with  a  diagnosis 
of  acute  nephritis  are  found  on  microscopical  examination 
to  be  chronic  is  especially  impressive. 

As  the  disease  advances  into  the  tertiary  stage  the  symp- 
toms peculiar  to  the  secondary  stage  are  gradually  lost  as  the 
more  alarming  syndrome  develops.  The  patient  sinks  grad- 
ually and  dies  with  a  diagnosis  of  nephritis,  myocarditis  or 
some  other  condition  degenerative  in  character,  affecting  some 
vital  organ. 

An  enterocolitis  with  this  type  of  putrefaction  may  be 
called  the  great  moniliasis  of  the  temperate  zone.  Although 
many  authors  have  described  it  as  a  condition  of  little  moment, 
still  the  presence  of  oxalate  of  lime  crystals  in  the  tissues  and 
more  especially  in  the  kidneys  is  capable  of  causing  lesions 
from  which  the  patient  may  ultimately  be  incapacitated  or 
in  many  cases  meet  his  death. 


CHAPTER   IX 

THE  OLEIC  TYPE  OF  INTESTINAL 
PUTREFACTION 


There  are  certain  sufferers  from  enterocolitis  who  show  a 
decided  intolerance  of  fats  and  oils,  combined  with  severe 
disturbances  in  the  nervous  system.  This  latter  may  vary 
in  severity  from  pyschoses  of  very  alarming  character,  often 
requiring  institutional  treatment,  to  mild  neuralgias  or  neu- 
roses affecting  various  organs. 

The  onset  of  the  trouble  may  be  either  sudden  or  gradual, 
usually  sudden,  and,  as  in  many  other  intestinal  infections, 
the  importance  of  the  primary  sickness  may  be  overlooked. 
Rarely,  however,  will  patients  be  encountered  who  will  not 
give  a  history  of  an  acute  illness  of  greater  or  less  severity, 
from  which  they  date  the  beginning  of  their  troubles. 

The  primary  stage  may  begin  with  a  most  intense  prostra- 
tion of  both  mental  and  bodily  functions;  and  the  attack  is 
often  so  violent  as  to  cause  acute  mania,  suddenly  develop- 
ing melancholia,  insanity  or  in  some  cases  death. 

The  secondary  stage  is  usually  prolonged,  lasting  in  some 
instances  several  decades.  The  psychoses  that  have  devel- 
oped in  the  primary  stage  may  continue  or  may  disappear 
spontaneously.  Often  new  disturbances  of  cerebral  functions 
make  their  appearance  one  after  another,  until  the  patient 
is  unable  to  be  cared  for  outisde  of  some  hospital  for  the  in- 
sane. 

Another  class  of  individuals  develop  a  special  clinical  pic- 
ture, in  which  a  progressive  bodily  weakness,  mild  paralyses 
and  severe  intestinal  symptoms  play  an  important  part. 
Many  of  these  patients  show  an  extreme  sensitiveness  of  the 
cutaneous  surface  to  sunlight. 

The  intestinal  symptoms  in  the  primary  and  secondary 
stages  appear  of  so  little  moment,  in  comparison  with  others 
of  more  alarming  nature,  that  they  are  overlooked  or  ignored. 


56  THE  OLEIC  TYPE 

Three  or  four  stools  a  day  are  not  generally  regarded  as 
remarkable  by  the  average  attendant.  These  stools  are  at 
times  accompanied  by  considerable  burning  or  tenesmus,  but 
the  patient  is  generally  in  no  condition  mentally  to  take  much 
notice  of  the  fact.  In  the  secondary  stage,  while  light  yellow 
diarrhoeal  stools  are  often  found,  there  may  be  a  severe  grade 
of  constipation.  A  very  marked  increase  in  the  amount  of 
the  feces  is  always  present.  Mucus  may  or  may  not  be  pres- 
ent, and,  if  erosions  or  ulcerations  arise  as  a  complication, 
blood  in  greater  or  less  amount  may  be  passed. 

The  blood  begins  to  show  evidence  of  toxic  damage  very 
early  in  the  disease,  the  anemia  being  characterized  by  a 
rapid  destruction  of  erythrocytes.  It  is  rare  to  find  any 
marked  leucocytosis,  unless  the  special  point  of  attack  of 
the  intoxication  is  the  spleen  or  lymphatic  system. 

From  the  physical  examination  of  the  patient  little  light 
will  be  thrown  upon  the  conditon.  The  liver  may  be  smaller 
than  is  normal,  or  the  colon  may  show  the  signs  of  atonic  or 
spastic  colitis.  In  most  cases  the  abdominal  examination 
will  be  negative.  An  examination  of  the  feces,  however,  will 
reveal  the  cause  of  the  trouble. 

Macroscopically,  the  stools  may  be  soft,  hard  or  of  creamy 
consistency;  the  color  light  yellow,  yellowish  gray,  brownish 
gray  or  clay  colored,  the  brightness  of  their  color  varying 
with  the  amount  of  fat  crystals  that  they  may  contain;  mucus 
is  generally  present  in  considerable  amounts,  although  it 
may  be  absent.  The  reaction  of  these  stools  may  be  acid, 
neutral  or  alkaline.  They  are,  as  a  rule,  however,  acid  to 
litmus.  Emulsified  with  dilute  Lugol's  solution  and  exam- 
ined under  the  microscope  the  number  of  fat  crystals  present 
is  usually  remarkable.  These  may  appear  in  the  form  of 
needles,  crystals  or  in  the  form  of  sheaves.  The  size  of  these 
crystals  will  vary  according  to  the  kind  of  fat  most  abundant 
in  the  food.  As  these  crystals  are  examined,  one  is  impressed 
with  the  great  loss  of  fat  that  is  going  on  in  the  intestine. 
Soap  crystals  may  also  be  abundant.  Free  starch  and 
muscle  fasciculi  are  usually  absent. 

In  Gram  stained  preparations,  among  the  positive  micro- 


OF  INTESTINAL  PUTREFACTION  57 

organisms,  very  large  dumbbell  diplococci  with  capsules 
5  X  2.25  microns  in  dimensions  will  occupy  a  very  prominent 
place.  These  often  grow  in  the  form  of  large  streptococci  com- 
posed of  the  above  named  dumbbell  diplococci.  In  some 
specimens  the  edge  of  the  micro-organism  has  a  wavy  outline, 
putting  one  strongly  in  mind  of  the  form  taken  by  a  section 
of  inflated  colon.  In  some  specimens  of  feces  this  micro- 
organism may  be  present  in  almost  pure  culture.  Various 
other  forms  such  as  the  biscuit  shaped  bacterium  Welchii, 
the  smaller  sausage-shaped  rods,  the  bacillus  bifidi,  and  a  few 
Clostridia  are  generally  present  in  moderate  numbers.  Un- 
less the  feces  have  been  retained  in  the  colon  until  bacterial 
autolysis  has  taken  place,  the  dumbbell  diplococci  will  be 
found  abundant  and  of  luxuriant  growth. 

Among  the  Gram  negative  forms  very  large  hyphae  10 
to  12  microns  in  length  by  2  microns  in  width,  which  often 
contain  large  polar  or  sub-polar  transparent  spores,  will  be 
noted.  These  rods  at  times  stain  positively  in  areas.  Many 
fine  rods  closely  resembling  the  bacillus  liquefaciens  ilei  will 
be  abundant,  especially  in  soft  or  liquid  stools.  The  bacillus 
coli,  when  the  disease  is  of  mild  nature,  is  uniformly  present. 
In  the  more  severe  conditions,  however,  it  is  generally  absent. 

In  preparations  stained  with  carbolic  thionine  the  dumb- 
bells and  large  Gram  negative  bacilli  will  be  stained  a  dark 
blue  in  distinction  to  the  other  micro-organisms,  which  appear 
violet  in  tint.  Often  other  large  conidia-like  bodies,  stain- 
ing diffusely,  with  transparent  areas  will  be  found  in  these 
specimens. 

Smears  stained  with  strong  Lugol's  solution  are  usually 
negative.  Occasionally,  the  large  transparent  spores,  men- 
tioned above,  will  be  shown  very  plainly,  often  in  masses 
of  seven  to  ten.  The  field  may  be  mixed,  lightly  or  abso- 
lutely positive,  but  never  negative. 

Feces  sown  on  glucose  agar  media  at  the  end  of  three  days 
show  a  slimy,  flat  growth,  spreading  over  the  surface.  This 
growth  is  white  with  a  yellow  tinge  with  even  border  and  is 
slightly  raised  above  the  surface  of  the  agar.  In  Gram  stained 
preparations  of  this  growth  a  few  irregularly  shaped  hyphae 


58  THE  OLEIC  TYPE 

will  be  noted  but  no  well  developed  mycelia.  The  conidia 
will  be  fusiformed,  capsulated  and  if  sufficiently  decolorized 
with  alcohol  or  nitric  acid  alcohol  will  show  characteristic 
Gram  positive  polar  dots.     This  is  a  mold  of  the  genus  torula. 

Much  work  remains  to  be  done  upon  the  molds  that  gain 
their  living  in  the  intestinal  contents.  It  is  probable  that 
many  disagreeable,  if  not  dangerous  or  fatal  disturbances 
which  are  occasionally  encountered  in  clinical  work  may  be 
attributed  to  the  toxins  and  enzymes  that  they  produce  in 
their  metabolism. 

Judging  from  the  amount  of  free  oleic,  palmitic,  stearic 
and  other  heavy  fatty  acids  that  are  present  in  the  feces  in 
this  condition,  there  must  be  an  enzyme  of  remarkable  activ- 
ity produced  in  the  intestinal  lumen.  Fat  needles  are  often 
found  in  feces  of  individuals  who  do  not  show  the  same  severe 
nervous  symptoms  that  have  been  described.  In  this  case, 
however,  the  fecal  fields  do  not  show  the  presence  of  the 
oleic  type  of  putrefaction  and  when  this  latter  condition  per- 
tains, some  pancreatic  disease  of  a  functional  or  organic 
nature  should  be  suspected. 

While  admitting  that  oleic  acid  and  its  near  neighbors  in 
the  fatty  acid  series  may  be  toxic,  when  used  subcutaneously, 
it  is  difficult  to  believe  that  the  great  damage  to  the  nervous 
system,  encountered  in  this  type  of  putrefaction,  can  be 
accounted  for  on  the  theory  of  oleic  acid  absorption  from  the 
intestines.  It  seems  much  better  to  explain  this  group  of 
symptoms  upon  the  basis  of  a  lipase  intoxication  arising  from 
the  metabolic  activity  of  micro-organisms  in  the  intestinal 
contents.  Sufferers  from  this  type  of  enterocolitis,  when  the 
excessive  fat  splitting  process  is  checked,  show  a  most  remark- 
able improvement  in  their  mental  and  nervous  condition. 

The  urine  is  usually  negative  both  microscopically  and 
chemically. 

The  tertiary  stage  in  this  type  of  putrefaction  is  character- 
ized by  marked  degenerative  changes  in  the  nervous  system. 
The  brain  is  the  usual  seat  of  this  attack  and  the  more  severe 
pyschoses  when  present  render  it  absolutely  necessary  that 
the  patient  pass  his  days  in  some  institution. 


CHAPTER  X 

THE  AMMONIACAL  TYPE  OF  INTESTINAL 
PUTREFACTION 


There  is  a  type  of  enterocolitis  of  a  very  severe  grade,  in 
which  ammonium  is  produced  in  great  quantities  in  the 
intestinal  canal,  accompanied  by  a  persistent  diarrhoea, 
great  physical  weakness  and  a  very  high  grade  of  anemia. 

In  the  primary  stage  great  and  sudden  prostration,  diag- 
nosed as  neurasthenia,  with  rarely  a  rise  in  temperature,  a 
weak  and  rapid  pulse,  vomiting,  abdominal  pain  and  tender- 
ness often  so  severe  as  to  suggest  an  acute  peritonitis,  are  all 
prominent  symptoms.  Commonly  diarrhoeal  stools  are  pres- 
ent, often  containing  mucus  and  blood  or  bloody  mucus.  In 
some  instances,  however,  persistent  constipation  will  be 
found.  The  discharges  per  anum  may  contain  very  little, 
if  any  fecal  matter  and  may  consist  solely  of  mucus  or  muco- 
pus.  The  illness  may  be  so  severe  as  to  cause  death  or  con- 
valescence may  be  prolonged  for  months  or  even  years. 

The  secondary  stage  may  last  for  several  decades  and 
patients  passing  through  this  stage  are  usually  great  sufferers. 
There  is  rarely  impairment  of  the  mental  faculties,  but  neu- 
ralgia of  great  severity  is  a  very  frequent  symptom.  Attacks 
of  herpes  zoster  are  very  common,  often  followed  by  post- 
perpetic  neuralgias,  which  make  the  patient's  life  one  of  misery. 
The  circulatory  systems  show  a  marked  weakness  of  the 
musculature  of  the  heart  and  blood  vessels,  but  rarely  is 
there  any  increase   in   blood  pressure  or  an  arteriosclerosis. 

In  the  urinary  system  secondary  infections  are  generally 
the  rule,  leading  to  pyelitis  and  cystitis  with  ammoniacal 
urine.  The  precipitation  of  the  earthy  phosphates  of  the 
urine  is  very  common  and  in  patients  who  have  suffered  for 
several  years  from  this  type,  one  or  more  phosphatic  cal- 
culi are  usually  present,  in  the  kidneys,   ureter  or  bladder. 


60  THE  AMMONIACAL  TYPE 

The  liver  may  be  enlarged,  its  lower  border  swollen,  rounded 
and  soft.  The  gall  bladder  and  gall  ducts  may  also  be 
the  seat  of  calculus  formation.  The  colon  may  be  palpable, 
prolapsed,  distended,  crepitant  or  knotty  from  the  presence 
of  scybala.  Intense  pain  may  be  referred  to  its  location  with 
burning  of  greater  or  less  degree.  Under  X-ray  examination, 
portions  may  be  found  showing  constrictions,  which  may  be 
either  organic  or  spastic  in  origin. 

The  urine  is  light  in  color,  cloudy  from  the  presence  of  pus 
or  earthy  phosphates  and  intensely  ammoniacal  in  odor.  The 
reaction  is  uniformly  alkaline.  The  specific  gravity  is  as  a 
rule  so  low  as  to  lead  to  a  suspicion  of  an  incipient  inter- 
stitial nephritis.  As  recovery  takes  place,  however,  the 
specific  gravity  usually  rises  to  normal.  Albumen  may  be 
present  in  greater  or  less  amount.  An  indicanuria  of  high  or 
low  grade  may  be  present,  but  is  not,  in  simple  cases,  prom- 
inently so.  Diacetic  acid  may  or  may  not  be  present  and 
also  skatol. 

Upon  microscopical  examination,  the  great  number  of 
crystals  of  ammonium  magnesium  phosphate,  together  with 
the  abundance  of  earthy  phosphates,  will  be  remarkable. 
The  presence  of  casts  of  various  types  gives  the  condition  a 
place  in  the  tertiary  stage  and  organic  elements  are  rarely 
found  in  the  secondary  stage. 

The  feces  may  be  liquid,  watery,  formed  or  scybalous. 
The  color  may  vary  from  yellowish  gray  in  diarrhoeal  to  dark 
brown  in  scybalous  stools.  Mucus  may  or  may  not  be  ex- 
tremely abundant.  The  intense  ammoniacal  odor  of  these 
stools  is  remarkable.  The  stools  are  always  strongly  alkaline. 
Litmus  paper  wet  with  water  and  held  over  the  mouth  of  the 
container  will  be  turned  blue. 

Microscopically,  with  dilute  Lugol's  solution,  free  starch 
is  absent,  muscular  fasciculi  are  absent,  a  few  fat  needles 
may  be  noted,  yeast  cells,  usually  of  the  round  variety,  will 
be  abundant,  while  of  the  crystalline  bodies,  the  number  of 
triple  phosphates  will  be  a  cause  for  remark.  Many  soap 
crystals  will  also  be  found. 

In  the  Gram  stained  field,  among  the  positive  forms,  the 


OF  INTESTINAL  PUTREFACTION  61 

presence  of  streptococci  will  be  especially  noticeable.  Many 
of  the  capsulatus  type  will  be  found,  as  these  grow  luxuriantly 
in  alkaline  feces.  If  ulceration  is  present,  cocci  and  staphylo- 
cocci will  be  abundant,  their  number  varying  with  the  nature 
and  extent  of  the  suppurative  process.  Long  filamentous 
forms,  apparently  belonging  to  the  B.  putrificus  group,  are 
very  abundant.  Occasionally,  Clostridia  will  be  present,  the 
alkaline  intestinal  contents  furnishing  a  very  favorable 
medium  for  the  growth  of  acid  producing  bacteria. 

In  the  Gram  negative  field,  many  large  rod-like  micro- 
organisms will  usually  be  observed.  These,  apparently,  are 
the  hyphae  of  molds  and  may  have  sections  taking  the  posi- 
tive stain  with  more  or  less  intensity. 

Various  negative  forms,  such  as  the  B.  liquefaciens  ilei  may 
be  present.  The  colon  bacilli  in  the  more  severe  types  are 
absent.  In  their  absence  or  presence,  and  if  present  their 
number,  we  find  a  very  useful  method  of  estimating  the 
severity  of  the  intestinal  condition. 

In  the  preparations  stained  with  carbol  thionine  the  micro- 
organisms are  generally  stained  blue.  The  capsulatus  types 
usually  take  the  violet  tint  which  is  characteristic  in  speci- 
mens from  the  various  types  of  putrefaction. 

With  the  specimens  stained  with  strong  Lugol's  solution, 
free  starch  detritus  is  very  regularly  present.  Clostridia 
may  or  may  not  be  present.  Often  the  micro-organisms  in 
the  immediate  neighborhood  of  the  free  starch  granules  take 
the  iodine  stain  in  the  less  serious  types  of  this  putrefaction. 

The  microscopical  field  varies  from  absolutely  positive  to 
mixed,  concomitantly  with  the  severity  of  the  enteric  catarrh. 

There  are  many  patients  in  whom  the  severity  of  this 
intestinal  condition  is  masked  through  the  coexistence  of  a 
putrefaction  of  an  acid  type.  So  long  as  the  production  of 
acids  and  ammonia  is  about  evenly  balanced,  these  patients 
enjoy  fair  health  and  are  able  to  perform  their  daily  tasks  in 
comparative  comfort.  At  times,  either  through  changes  in 
the  character  of  their  diets,  or,  perhaps,  through  the  acqui- 
sition of  new  and  more  active  strains  of  either  acid  or  alkali- 
producing  bacteria,   the  balance  is   upset,   and   they  suffer 


62  THE  AMMONIACAL  TYPE 

attacks  attributable  to  either  one  effect  or  the  other.  The 
character  of  this  condition  can  be  easily  discovered  through 
the  methods  of  examination  set  forth  in  the  previous  chapters. 
Marked  organic  lesions  do  not  generally  mark  the  tertiary 
stage  of  this  type  of  enterocolitis.  The  patients  are  gradually 
worn  down  by  attack  after  attack  of  an  acute  nature  until 
they  lapse  into  a  condition  best  described  by  the  term,  gen- 
eral debility.  A  rapidly  advancing  pernicious  anemia  or 
some  intercurrent  disease,  usually  ends  their  life  peacefully 
and  with  little  suffering. 


CHAPTER  XI 

THE  URIC  ACID  TYPE  OF  INTESTINAL 
PUTREFACTION 


There  are  certain  patients,  the  victims  of  mild  grades  of 
enterocolitis,  in  whom  there  seems  to  be  a  chronic  deficiency 
of  oxidizing  power.  This  may  be  a  matter  of  heredity, 
acquired  as  the  result  of  sedentary  habits  combined  with  the 
habitual  ingestion  of  great  quantities  of  highly  nutritious 
food,  or  the  result  of  exhaustion  of  the  oxidizing  function 
through  the  consumption  of  alcohols,  ethers,  aldehydes,  acids 
and  aromatic  bodies  found  regularly  in  the  products  of  the 
vineyard  and  of  the  still.  In  consequence,  a  very  slight  in- 
crease in  intestinal  putrefaction  upsets  their  metabolic  equi- 
librium, while  any  sudden  increase  in  the  production  of  acids 
in  the  digestive  canal  brings  on  an  attack  of  gout  of  a  severity 
varying  concomitantly  with  the  enteric  condition. 

The  important  point  in  these  cases,  however,  is  that  there 
is  an  intestinal  putrefaction  of  some  type  present,  not  only 
at  the  time  of  the  paroxysm,  but  also  during  the  time  when 
gouty  symptoms  are  absent.  If  this  can  be  checked  and  a 
normal  condition  of  the  intestinal  mucosa  brought  about,  the 
patient  will  experience  no  further  difficulty.  The  intestinal 
condition  may  be  diagnosed  through  the  methods  laid  down 
in  this  work. 


CHAPTER  XII 
MALARIA.  SYPHILIS  AND  TUBERCULOSIS 


In  every  case  of  enterocolitis,  no  matter  what  the  type  of 
putrefaction  may  be,  an  investigation  of  the  possibiUty  of 
a  malarial,  syphilitic  or  tubercular  infection,  singly  or  in 
combination,  should   always  be  conducted. 

Malaria  is  one  of  the  most  common  diseases  of  civilization. 
The  malarial  chill  occurring  every  two  or  three  days  has,  in 
New  England,  become  a  rarity.  In  its  place  we  find  the 
chronic,  deep-seated  infections  of  long  standing  in  which  a 
diagnosis  is  extremely  difficult  from  an  examination  of  the 
blood  unless  the  parasites  are  in  the  swarming  stage.  Often 
two  or  more  types  of  malarial  parasites  may  be  found  in  the 
same  person.  The  spread  of  malaria  through  the  New  England 
states  may  be  laid  at  the  door  of  immigration.  The  subter- 
tian  type  is  the  most  prevalent. 

In  order  to  get  a  correct  clinical  picture  of  these  malarial 
conditions  we  must  regard  them  as  a  chronic  parasitic  disease 
of  the  liver,  spleen,  pancreas,  bone  marrow  and  other  organs, 
and  not  of  the  red  blood  cells  alone.  The  time  during  which 
these  parasites  lie  dormant  in  these  organs  may  be  passed  in 
comparative  comfort  so  far  as  the  patient  is  concerned.  At 
certain  seasons  of  the  year  when  the  blood  stream  is  invaded 
by  the  sexual  forms  of  the  Plasmodium,  or  their  growth  be- 
comes more  active,  various  intestinal  symptoms  are  prom- 
inent. These  may  vary  from  distress,  burning,  epigastric 
unrest,  diarrhoea  or  constipation,  to  pain  in  the  right  side 
of  the  abdomen  so  severe  as  to  simulate  appendicitis. 

There  is  usually  no  rise  in  temperature  at  the  time  of  these 
attacks.  Upon  physical  examination,  the  liver  is  usually 
found  swollen  and  palpable  and  often  tender.  An  examina- 
tion of  the  blood  will  show  a  mild  leucocytosis. 

Better  results  will  be  obtained  in  the  search  for  plasmodia 


MALARIA,  SYPHILIS  AND  TUBERCULOSIS  65 

if  the  blood  is  examined  after  the  method  of  Manson.  A 
glass  slide  and  cover  glass  are  first  carefully  cleaned  with 
alcohol.  It  is  especially  important  that  these  should  be  abso- 
lutely free  of  all  grease,  before  spreading  the  blood.  The 
lobe  of  the  ear  is  next  punctured  with  a  small  lancet  or  a  three- 
cornered  needle,  a  very  small  drop  of  blood  placed  in  the 
centre  of  the  cover  glass,  great  care  being  taken  that  the  glass 
does  not  touch  the  skin.  The  slide  is  then  breathed  upon 
and  the  cover  glass  placed  blood  downward  upon  it.  This 
process  must  be  done  quickly  in  order  that  the  drop  of  blood 
may  not  dry.  When  this  is  properly  done,  three  zones  will 
be  noted  in  the  preparation.  The  central  zone  should  be 
absolutely  transparent  and  colorless,  the  middle  zone  should 
have  a  delicate  pinkish  yellow  tint  and  the  outer  zone  should 
be  blood  red.  When  examined  with  a  twelfth  oil  immersion 
lens,  in  the  central  or  colorless  zone  the  blood  will  show 
scattered  erythrocytes,  resting  flat  between  the  two  glass 
surfaces.  In  the  light  colored  zone  the  red  cells  will  be  over- 
lapping or  rouleated  with  clear  spaces  between.  The  red 
area  will  consist  of  closely  packed  red  cells  with  here  and 
there  a  leucocyte.  The  central  transparent  area  should  be 
carefully  searched  for  plasmodium,  either  within  or  upon  the 
red  cells.  The  second  area  should  be  examined  for  active  para- 
sites and  for  micro-  and  macrogametes.  These  will  not  be  found 
in  the  transparent  area  as  the  pressure  of  the  cover  glass  upon 
the  glass  slide  prevents  them  from  freeing  themselves  from 
the  red  cells.  These  gametes  at  room  temperature  are  gen- 
erally extremely  active. 

Stained  blood  smears  are  usually  of  less  value  than  fresh 
preparations. 

The   malarial   infections   met   with    may   be   classified   as 
follows : 

The  Quartian  Type,  Plasmodium  malariae. 

The  Tertian  Type,  Plasmodium  vivax. 

The  Pigmented  Quotidian  Type,  Laverania  praecox. 

The  Unpigmented  Quotidian  Type,  Laverania  immacu- 
lata. 

The  Subtertian  Type,  Laverania  malariae. 


66  MALARIA,  SYPHILIS  AND  TUBERCULOSIS 

Any  organ  of  the  body  may  become  sensitized  to  the  mala- 
rial protein.  The  symptoms  that  the  patients  show  will 
depend  upon  which  tissues  have  acquired  the  power  of  digest- 
ing the  protein  of  the  plasmodia.  The  blood  cells  may  have 
acquired  this  property  and  the  remainder  of  the  body  paren- 
chyma, not  having  the  same  power,  may  remain  intact.  In 
this  case  a  true  picture  of  pernicious  anemia  will  be  given. 
So,  also,  the  epithelium  of  the  mucous  glands  and  follicles  of 
the  intestinal  canal  may  become  sensitized  to  this  poison  and 
the  other  organs  of  the  body  remain  unsensitized.  In  this 
case  the  patient  will  give  a  history  of  subacute  attacks  or 
exacerbation  of  a  low  grade  catarrhal  process,  limited  to  the 
intestinal  canal.  Having  confirmed  the  diagnosis  by  a  micro- 
scopical examination  of  the  blood,  it  is  extremely  interesting 
to  follow  the  course  of  the  intestinal  symptoms  under  anti- 
malarial treatment.  Most  of  these  cases  are  made  very  much 
worse  by  quinine,  at  least  during  the  first  week  of  treatment. 
The  reason  for  these  untoward  symptoms  arises  from  the 
fact  that  the  tissues  of  the  intestinal  canal  during  this  period 
are  called  upon  to  digest  the  malarial  protein  arising  from 
the  death  of  the  plasmodia  through  the  toxic  action  of  quinine, 
in  far  greater  amount  than  before.  In  about  two  weeks 
after  the  beginning  of  anti-malarial  treatment,  it  will  be  uni- 
versally found  that  larger  doses  than  those  used  in  the  begin- 
ning may  be  used  without  disagreeable  symptoms. 

The  fact  must  be  borne  in  mind  that  in  many  of  these  in- 
dividuals the  power  of  digesting  particulate  malarial  protein 
bodies  has  been  exhausted.  In  other  words,  that  the  patient 
has  developed  a  condition  often  termed  anti-anaphylaxis. 
The  blood  in  this  condition  will  show  a  marked  leucopenia. 
The  scarcity  of  the  white  cells  and  also  their  lack  of  vitality 
will  be  noted  in  the  fresh  blood  preparations  if  the  warm  stage 
is  used  with  the  microscope.  In  normal  blood  preparations 
the  living  leucocytes  should  never  take  the  spherical  form  at 
body  temperature.  The  normal  leucocyte  is  always  angular 
or  amoeboid  in  form.  Therefore,  so  far  as  the  leucocytes  go, 
the  number  of  these  cells  may  be  used  as  a  guide  to  the  re- 
sistance of  our  patients  against  the  infection. 


MALARIA,  SYPHILIS  AND  TUBERCULOSIS  67 

The  cover  glass  had  better  be  ringed  with  vaseline  to  pre- 
vent evaporation  in  the  blood  film  and  consequent  crenation 
of  the  red  cells  that  might  simulate  plasmodia  attached  to 
the  cell  surface.  An  abundance  of  crenated  erythrocytes 
indicates  a  deficient  vitality  of  the  red  cells.  If  any  of  these 
cells  have  a  to-and-fro  motion,  we  may  assume  that  a  malarial 
parasite  is  attached  to  it.  The  study  of  the  minute  bodies 
observed  in  the  plasma  of  the  fresh  preparation  will  lead  the 
examiner  to  conclude  that  possibly  a  sexual  cycle  takes  place 
in  the  blood  stream,  as  well  as  in  the  mosquito. 

The  organisms  are  often  pear-shaped,  motile  and  appear 
to  attach  themselves  to  the  red  cells  by  their  smaller  extrem- 
ity. Often  small  poikilocytes  and  microcytes  will  be  seen  in 
motion,  traveling  across  the  field,  towed  by  these  pear- 
shaped  micro-organisms.  When  these  larger  bodies  are  free- 
swimming  they  take  the  form  of  a  dumbbell.  Their  motion 
is  very  active.  Their  bodies  are  highly  refractile  and  the 
cytoplasm  shows  evidence  of  intracellular  circulation.  Appar- 
ently this  body  eventually  divides  the  two  pear-shaped  bodies. 

Crescents  will  also  be  noted  attached  to  withered  or  cre- 
nated erythrocytes.  This  form  is  not  so  active  as  the  pear- 
shaped  and  dumbbell  forms.  They  are  rather  hard  to  dis- 
tinguish under  the  microscope  as  the  light  transmitted  through 
the  red  cells  gives  their  bodies  the  same  tint  as  the  colored 
corpuscles  of  the   blood. 

The  course  of  malarial  infection  may  be  divided  into  four 
stages.  First,  the  stage  of  invasion;  second,  the  stage  begin- 
ning with  the  establishment  of  sensitization,  which  may  be 
called  the  anaphylactic;  third,  the  stage  in  which  the  growth 
of  the  Plasmodia  and  the  parenteral  digestion  of  the  malarial 
protein  is  evenly  balanced;  fourth,  the  stage  in  which  the 
power  for  protein  digestion  has  been  exhausted  and  the  pa- 
tient enters  a  condition  usually  described  as  anti-anaphylaxis. 

The  primary  stage  or  the  stage  of  invasion  is  devoid  of 
serious  symptoms.  The  patient  may  have  certain  prodo- 
mata,  such  as  mild  headache,  slight  loss  of  appetite,  weakness 
and  lack  of  endurance,  but  does  not  consider  himself  ill. 

The  second  stage  usually  begins  with  a  pronounced  chill, 


68  MALARIA,  SYPHILIS  AND  TUBERCULOSIS 

followed  by  a  rise  in  temperature,  which  in  turn  is  followed  by 
profuse  perspiration.  This  corresponds  to  the  time  when 
the  patient's  sera,  leucocytes  and  tissue  cells  have  acquired 
the  power  of  digesting  the  particulate  protein  of  the  mala- 
rial Plasmodia.  This  stage  may  last  from  one  day  to  two 
weeks,  depending  upon  the  strength  of  the  special  strain  of 
malarial  plasmodia  that  are  invading  the  body. 

In  the  third  stage,  very  few  symptoms  will  be  shown  out- 
side of  a  weakness  and  loss  of  strength  and  endurance. 

In  the  fourth  stage,  where  the  resistance  against  the  attack 
of  the  Plasmodia  has  been  completely  exhausted,  the  patient's 
life  becomes  one  of  great  misery.  In  this  stage,  the  symp- 
toms may  be  referred  to  any  of  the  specialized  organs,  either 
singly  or  in  groups  embracing  two  or  more  organs.  The  cen- 
tral nervous  system  is  very  apt  to  be  the  seat  of  attack  and 
certain  comatose,  paralytic  or  neuralgic  conditions  may  be 
encountered.  In  the  tropics  these  conditions  are  frequent 
and  fatal,  but  in  the  temperate  zone,  while  not  so  severe,  they 
are  far  more  common  than  is  realized.  Conditions  diagnosed 
as  serous  apoplexy,  sudden  cerebral  congestions,  severe  neu- 
ralgias and  attacks  of  herpes  zoster,  with  or  without  posther- 
petic neuralgias,  may  be  caused  by  a  chronic  malarial  infec- 
tion in  the  fourth  stage.  The  circulatory  system  may  be  the 
point  of  attack  and  various  functional  cardiac  disorders, 
often  accompanied  by  a  rise  in  blood  pressure,  irregular  heart 
action  and  precordial  pain  will  be  noted.  If  the  liver  is  the 
point  of  attack,  pain  referred  to  the  right  side  of  the  abdomen, 
jaundice,  swelling  of  the  liver,  attacks  with  fever,  often  de- 
scribed in  the  tropical  countries  as  bilious  remittent  fever, 
will  occur.  The  pancreas  may  also  be  the  seat  of  attack  with 
glycosuria,  pain  and  fatty  stools.  The  kidneys  may  also  be 
attacked  and  syndomata  resembling  the  black  water  fever 
of  the  tropics,  but  much  less  severe,  may  be  observed.  In- 
testinal symptoms  will  often  be  prominent.  These  usually 
show  a  certain  periodicity  and  may  be  accompanied  by  con- 
stipation or  diarrhoea,  a  great  increase  in  the  amount  of 
flatus  and  an  abundance  of  mucus  in  the  stools.  Pain  is  apt 
to  be  a  prominent  symptom  and  may  be  referred  to  any  por- 


MALARIA,  SYPHILIS  AND  TUBERCULOSIS  69 

tion  of  the  abdomen.  So  severe  may  these  pains  be  as  to 
simulate  appendicitis,  biliary  colic,  and  many  of  the  opera- 
tions undertaken  for  the  relief  of  the  two  latter  conditions 
in  which  no  lesion  of  the  appendix  or  the  gall  bladder  are 
found  may  be  laid  at  the  door  of  this  disease. 

A  few  words  upon  the  life  history  of  the  micro-organism 
of  subtertian  malaria  may  be  of  interest.  Let  us  begin  with 
the  mosquito  of  the  variety  anopheles,  in  which  the  salivary 
glands  are  charged  with  the  microzoon  of  this  disease.  Upon 
biting  a  human  being  the  germ  enters  the  lymph  channels 
or  the  capillaries.  In  a  longer  or  shorter  time,  depending 
upon  the  number  of  organisms  introduced,  the  body  fluids 
will  contain  billions  of  plasmodia.  This  may  or  may  not  be 
followed  by  a  sensitization  of  the  general  parenchyma  or  of 
certain  organs  or  groups  of  organs.  The  more  general  the 
sensitization,  the  less  liable  will  the  patient  be  to  a  chronic 
malarial  infection.  The  entire  crop  of  plasmodia  may  be  de- 
stroyed at  the  time  of  the  first  chill.  On  the  other  hand,  sev- 
eral chills,  each  one  of  less  severity  than  its  predecessor,  may 
lead  on  into  the  third  stage  of  chronic  malaria.  If  this  occurs, 
the  Plasmodia  penetrate  deeper  and  deeper  into  the  body 
tissues  and  are  found  no  longer  in  the  peripheral  circulation, 
finding  their  abode  in  the  liver,  spleen,  brain  or  bone  marrow. 
At  certain  periods  these  plasmodia  set  free  a  host  of  micro- 
and  macrogametes,  but  between  times  the  blood,  so  far  as 
micro-organisms  are  concerned,  is  free  of  malarial  forms.  The 
time  of  swarming  usually  corresponds  with  the  period  of 
malarial  symptoms  in  the  individual.  If  blood  containing 
these  forms  is  eaten  by  the  anopheles,  the  mosquito  becomes 
infected  and  can  transmit  the  disease.  On  the  other  hand, 
two  cycles  may  take  place  within  the  body,  an  asexual  and  in  all 
probability  a  sexual  cycle.  The  latter  type  of  propagation 
seems  very  probable,  in  view  of  the  fact  that  asexual  propa- 
gations among  all  protozoa,  without  the  introduction  of  new 
individuals  in  the  chain,  eventually  result  in  the  degenera- 
tion of  that  individual  colony.  Many  of  the  blood  pictures 
seen  in  the  study  of  chronic  malaria  lead  to  the  prediction 
that  this  will  some  day  be  proven. 


70  MALARIA,  SYPHILIS  AND  TUBERCULOSIS 

It  seems  also  probable  that  malaria  may  be  transmitted  in 
other  ways  than  through  the  agency  of  anopheles.  More 
especially  when  we  consider  the  minuteness  and  motility  of 
the  micro-  and  macrogametes  of  the  subtertian  plasmodia. 
Possibly,  as  in  syphilis,  this  type  may  be  transmitted  by 
direct  contact  with  abraded  surfaces,  or  upon  the  ovules  or 
microgametes  of  human  beings. 

Often  no  second  stage  will  be  noted  and  the  patient  will 
become  malarialized  without  having  any  of  the  classic  symp- 
toms of  an  acute  malarial  infection.  This  will  account  for 
many  of  the  chronic  malarias  that  give  no  history  of  any 
acute  attack. 

Three  types  of  syphilis  will  be  met  with  as  complications 
in  enterocolitis.  The  first  type  includes  ulcerations,  gum- 
mata  and  other  purely  local  lesions  of  the  intestinal  canal. 
The  second  type  includes  syphilitic  disease  of  the  liver,  pan- 
creas and  spleen.  The  third  type  includes  diseases  of  the 
nervous  system,  acting  reflexly  upon  the  intestinal  canal  and 
also  lesions  of  the  intestinal  mucosa,  corresponding  in  their 
pathological  processes  to  the  tertiary  lesions  found  upon  the 
skin.  In  the  first  two  types  the  Wasserman  reaction  is 
usually  positive  for  the  blood.  In  the  third  type  the  cerebro- 
spinal fluid  will  be  positive  and  the  blood  negative.  In  the 
first  type  the  lesions  will  be  caused  by  the  direct  attack  of 
the  treponema.  In  the  second,  the  symptoms  will  be  second- 
ary to  syphilitic  disease  in  the  organs  supplementary  to  in- 
testinal digestion.  In  the  third,  the  symptoms  will  arise 
from  the  disturbance  of  the  correlation  of  the  mechanical  and 
chemical  processes  of  digestion,  in  the  first  case,  and  in  the 
second,  from  sensitization  phenomena  without  the  local  pres- 
ence of  the  micro-organism  of  the  disease. 

The  lungs  should  always  be  carefully  examined  for  tuber- 
cular lesions  and  the  possibility  of  tubercular  foci  in  other 
organs  should  always  be  considered.  Primary  tuberculosis 
of  the  intestinal  mucosa,  while  rare,  is  always  possible  as  a 
complication  of  an  intestinal  catarrh.  If  ulceration  is  pres- 
ent, tubercule  bacilli  and  blood  will  be  present  in  the  feces. 
A  search  for  tubercule  bacilli  is  always  important  in  the 
examination  of  feces. 


CHAPTER  XIII 

THE  PROTEIN  POISON 


Protein  sensitization  or  anaphylaxis  occupies  a  very  prom- 
inent position  in  many  of  the  problems  of  enterocolitis,  and 
the  parenteral  digestion  of  foreign  protein  bodies  and  the 
poisonous  effect  of  the  split  products  of  this  digestion  should 
be  kept  in  mind.  These  bodies  may  enter  the  intestinal 
canal  with  the  food,  in  the  mucus  from  the  nose  and  throat  or 
arise  as  the  result  of  bacterial  growth  in  the  intestinal  canal, 
the  passages  connected  therewith  or  in  the  mucosa  or  sub- 
mucosa  that  lines  them. 

In  nearly  every  individual,  the  phenomena  of  sensitization 
against  certain  proteins  can  be  found.  In  some  the  pro- 
teins of  fish,  in  others  those  of  eggs,  while  in  others  those  of 
certain  vegetables  and  fruits  cause  disagreeable  symptoms 
or  at  least  are  extremely  distasteful.  Other  sufiferers  from 
enterocolitis  notice  that  certain  months  of  the  year  are  es- 
pecially uncomfortable  so  far  as  their  intestinal  condition  is 
concerned,  and  so  regular  is  the  recurrence  of  these  periods 
that  a  direct  connection  with  some  of  the  pollens  that  cause 
hay  fever  sufiferers  so  much  trouble  may  be  suspected.  The 
desquamations  of  some  of  the  lower  animals  may  also  be  a 
cause  of  trouble. 

In  the  primary  stage  of  enterocolitis,  sensitization  phenom- 
ena are  generally  very  prominent,  often  alarming  in  their 
intensity  and  may  in  certain  cases  be  the  cause  of  sudden 
death.  Most  of  the  attacks  of  acute  indigestion  are  caused 
by  the  so-called  protein  poison,  arising  from  the  digestion 
of  the  particulate  protein  of  bacteria  or  of  soluble  proteins 
that  have  escaped  the  action  of  the  enzymes  normally 
present  in  the  intestinal  canal. 

The   mucous   surfaces  of  certain   individuals   seem   to  be 


72  THE  PROTEIN  POISON 

especially  permeable  to  certain  protein  bodies.  Ulcerated 
or  eroded  surfaces  and  large  areas  of  scar  tissue  make  this 
absorption  especially  hard  to  control. 

In  the  case  of  the  particulate  proteins,  namely  the  micro- 
organisms, this  sensitization  gives  complete  protection  against 
the  further  attack  of  the  invading  parasite  so  long  as  this 
immunity  lasts.  In  the  case  of  the  soluble  proteins,  however, 
the  amount  absorbed  may  be  great  enough  to  exhaust  the 
sensitization  of  the  cells  of  the  body  and  bring  on  the  condi- 
tion termed  anti-anaphylaxis.  This  condition  is  present  in 
many  cases  of  enterocolitis.  Consequently,  the  success  or 
failure  of  our  efforts  to  relieve  our  patients  depends  upon 
our  ability  to  find  which  proteins  are  harmful  and  which  are 
well  borne. 

The  symptoms  in  the  primary  stage  may  best  be  grouped 
under  the  term  acute-anaphylactic  or  sensitization  shock.  These 
are  paralysis  of  the  voluntary  muscles,  a  greatly  reduced 
blood  pressure,  a  spasm  of  the  bronchi  and  death  by  suffo- 
cation resulting  from  this  spasm.  This  train  of  symptoms 
is  present  in  every  sufferer  from  acute  indigestion.  The 
patient  falls,  struggles  for  breath,  goes  into  a  state  of  syncope, 
respiration  ceases,  and  he  dies,  so  to  speak,  with  his  heart 
still  beating.  If  recovery  takes  place  the  respiration  first 
returns,  the  weakness  rapidly  disappears  and  the  patient 
recovers  in  a  remarkably  short  time.  THe  prodroma 
that  are  noted  in  animal  experimentation  are  always  well 
marked,  namely  the  itching  of  the  skin  or  a  disturbance 
of  cutaneous  sensation. 


CHAPTER  XIV 

THE  TREATMENT  OF  ENTEROCOLITIS 


The  therapy  of  enterocolitis  furnish  many  problems  of 
great  interest.  Upon  the  success  or  failure  of  our  efforts,  the 
future  usefulness,  comfort  and  prosperity  of  our  patients  will 
depend.  It  is  well  to  realize  in  the  beginning  the  magnitude 
of  the  task,  to  gain  the  confidence  of  the  patient  and  to  avoid 
promising  too  speedy  a  recovery.  Many  of  the  patients  im- 
prove wonderfully  in  a  few  weeks,  take  false  courage  and 
believe  that  their  health  has  been  permanently  restored. 
Such  people  should  be  told  frankly  that  their  improvement 
may  be  temporary  and  that  the  fact  that  it  took  place  does 
not  affect  the  length  and  persistence  of  the  therapeutic  cam- 
paign. The  average  patient  expects  great  things  from  the 
physician  and  is  apt  to  form  a  poor  opinion  of  any  medicine 
that  does  not  bite  as  quickly  as  the  ubiquitous  cocktail. 
Procedures  that  neither  physic  nor  benumb  are  beyond  his 
comprehension.  Quick  results  are  always  expected  and  it  is 
hard  to  convince  him  that  the  physician  cannot  supply  that 
very  important  factor  in  the  treatment  of  his  disease,  namely 
time.  It  is  also  difficult  to  protect  your  patient  from  the 
advice  of  friends,  nurses  and  irregulars,  often  to  be  sure,  given 
with  the  best  intentions,  but,  from  a  psychological  stand- 
point, very  deleterious. 

While  realizing  that  humanity  is  prone  to  err  and  that  the 
physician  should  be  ever  ready  to  forgive  any  lapses  from 
routine  that  are  confessedly  the  result  of  human  weakness, 
still,  never  allow  a  patient  to  argue  this  question.  The  mat- 
ter should  be  brought  at  once  to  the  point  of  obey  or  find  some 
other  physician.  The  mental  process  of  the  patient  who  has 
a  history  and  physical  examination  completed,  submits  speci- 
mens of  gastric  contents,  feces  and  urine,  calls  once  and  is 
never  seen  again  is  hard  to  explain.     This  very  frequently 


74      THE  TREATMENT  OF  ENTEROCOLITIS 

happens  and  always  awakens  feelings  of  regret  that  the  time 
spent  in  the  study  of  the  case  has  been  wasted,  and  that  the 
laboratory  force  has  been  needlessly  exposed  to  danger. 

In  the  primary  stage  of  chronic  enterocolitis  more  can  be 
accomplished  with  a  little  treatment  than  in  any  other  known 
disease.  The  way  is  open  for  direct  local  therapeusis,  but  it 
is  absolutely  necessary  that  this  treatment  should  be  appro- 
priate for  the  condition  of  the  mucous  membrane  and  the  type 
of  infection. 

The  type  should  be  diagnosed  through  analysis  of  feces  and 
urine,  the  anatomical  features  cleared  up  by  a  thorough  phys- 
ical examination  and  a  search  for  any  organic  lesions  care- 
fully made. 

The  patient  had  better  rest  quietly  in  bed  until  the  acute 
period  is  passed  and  for  good  measure  a  few  days  more,  in 
order  that  his  strength  and  resisting  power  may  be  completely 
regained.  If  possible,  he  should  be  kept  under  observation 
until  the  urine  is  negative,  so  far  as  the  indices  of  intestinal 
putrefaction  are  concerned  and  the  fecal  fields  Gram-negative. 
If  after  a  month  has  elapsed,  the  chemical  and  bacteriological 
findings  are  still  negative,  the  patient  may  be  discharged  as 
cured.  If,  on  the  other  hand,  at  the  end  of  ten  days,  the 
chemical  and  microscopical  findings  are  still  positive,  the 
patient  may  get  up  and  about  and  gradually  resume  the  duties 
of  life,  provided  the  temperature  and  pulse  are  normal  and 
the  general  condition  warrants  it. 

Our  efforts  in  this  stage  should  be  directed  toward  the 
accomplishment  of  four  things:  First,  the  restoration  of  asep- 
tic conditions  in  the  gastrointestinal  canal;  second,  the  heal- 
ing of  the  catarrh;  third,  the  complete  digestion  of  any  foreign 
protein  bodies  that  have  found  their  way  into  the  mucosa  or 
into  the  body  tissues;  fourth,  the  limitation  of  the  amount  of 
damage  that  may  be  done  to  any  organ  during  the  course  of 
this  stage. 

To  accomplish  the  first  result,  the  administration  of  intes- 
tinal antiseptics  is  the  treatment  par  excellence.  To  avoid 
any  irritation  of  the  intestinal  mucosa,  they  should  be  given 
in  small  doses.    Certain  antiseptics  have  been  found  especially 


THE  TREATMENT  OF  ENTEROCOLITIS      75 

potent  against  certain  types  of  bacterial  invasion  and  the 
smallness  of  the  amount  required  to  produce  results  is  often 
surprising.  The  amount  of  the  salycilates  in  the  lymph  cir- 
culating through  the  ligaments  in  acute  articular  rheumatism 
must  be  very  small  and  yet  the  results  are  remarkable.  So 
also  the  results  that  we  may  get  from  the  use  of  antiseptics 
in  the  intestinal  canal  vary  with  what  we  might  term  the 
particularity  of  those  we  administer.  The  antiseptic  which 
in  the  smallest  doses  and  with  the  least  irritation  will  acccom- 
plish  the  greatest  good  is  the  one  to  be  preferred.  Intestinal 
antisepsis  is  still  a  matter  that  gives  great  room  for  research. 
The  day  is  not  far  distant  when  the  enzymes,  the  keys  fitted 
for  unlocking  the  proteins  and  toxins  of  each  special  type, 
will  be  in  common  use  for  the  benefit  of  humanity. 

In   clinical   investigations   the   following   antiseptics   have 
been  found  the  most  useful  in  the  acute  stages: 

Sodii  Salicylas. 

Dose;  Gms.  0.064  or  1  grain  every  two  hours. 

Hexamethylenamina. 

Dose:  Gms.  0.064  or  1  grain  every  two  hours. 

Oleum  Ricini. 

Dose:  Gms.  2.0  or  30  minims,  every  four  hours. 

Acidum  Nitricum  Dilutum. 

Dose:  Gms.  0.064  to  Gms.  0.128  or  Mi  to  Mii  every 
two  hours. 

Bismuthi  Subnitratis. 

Dose:  Gms.  0.250  or  Gr.  iv,  every  two  hours. 

Sodii  Benzoas. 

Dose:  Gms.  0.064  or  Gr.  i,  every  two  hours. 

Calomel  in  divided  doses. 

The  sodii  salicylas  will  be  found  most  useful  in  the  saccharo- 
butyric,  acetic  and  oleic  types  of  putrefaction.  The  hexa- 
methylenamina in  the  indolic  and  oxalic  types.  The  oleum 
ricini,  given  in  the  doses  mentioned  above,  is  almost  a  specific 
in  the  oleic  type  and  of  great  value  in  the  oxalic  types  of  putre- 


76      THE  TREATMENT  OF  ENTEROCOLITIS 

faction.  Bismuthi  subnitratis  and  acidum  nitricum  dilutum 
are  of  especial  service  in  the  oxalic  types,  although  the  bis- 
muth may  be  administered  with  advantage  to  most  sufferers 
from  enterocolitis  in  this  stage.  Occasionally,  it  acts  poorly, 
irritates  and  seems  to  encourage  rather  than  check  putre- 
faction. The  benzoate  of  soda,  while  of  little  value  by  itself , 
is  very  useful  in  combination  with  hexamethylenamina  in 
certain  individuals,  who  do  not  seem  to  cleave  the  latter. 

Calomel  in  small  doses  deserves  a  firm  place  among  the  most 
valuable  remedies  in  this  stage.  The  smaller  the  dose,  the 
better  its  action.  To  avoid  salivation  the  usual  saline  cathar- 
tic should  not  be  forgotten. 

Drugs  that  act  through  the  liberation  of  nascent  oxygen  in 
the  intestinal  canal  are  not  generally  a  success  in  the  pri- 
mary stage. 

The  catarrhal  process  may  best  be  handled  through  the 
diet.  The  catarrh,  however,  if  the  intestinal  putrefaction  is 
held  in  check,  usually  recovers  spontaneously.  As  a  routine 
treatment  the  tincture  of  belladonna  in  small  doses,  Gms. 
0.064  or  Mi,  every  two  or  three  hours,  seems  to  be  of  benefit. 
The  acidity  of  the  stomach  may  be  lessened  or  neutralized 
with  sodium  bicarbonate  and  sodium  bromide  may  be  used 
to  check  disagreeable  reflex  disturbances. 

Vomiting  from  reflex  irritation  of  the  intestine  or  of  the 
central  nervous  system  may  be  so  severe  as  to  require  the 
administration  of  morphine  by  hypodermic  injection  for  its 
relief. 

Sensitization  phenomena  may  form  a  very  important  part 
in  the  clinical  picture  in  this  stage  and  are  often  very 
severe  in  character.  Sudden  deaths  from  acute  indigestion 
are  usually  the  result  of  shock  resulting  from  the  production 
of  beta-iminazolylethylamin.  This  may  be  formed  in  the 
intestinal  canal  and  be  subsequently  absorbed,  or  from  the 
parenteral  digestion  of  foreign  protein  bodies,  which  have 
found  their  way  through  the  intestinal  mucosa.  These  for- 
eign proteins  may  be  introduced  with  the  food  or  be  the  re- 
sult of  bacterial  growth.  Death  is  usually  the  result  of 
bronchial    spasm,    the    heart   still    beating   after   respiration 


THE  TREATMENT  OF  ENTEROCOLITIS      77 

ceases.  The  treatment,  therefore,  should  be  directed  to  the 
relaxation  of  bronchial  spasm  and  to  raising  the  blood  pres- 
sure. The  first  can  be  best  and  most  quickly  accomplished 
by  ether  inhalation.  If  the  bronchial  spasm  has  reached  the 
point  of  respiratory  suspension,  the  hypodermic  method  may 
be  tried  or  tracheal  insufflation  of  ether  vapor  attempted. 
There  are  numerous  drugs  that  have  a  vaso  constrictive 
effect  and  may  be  administered  in  appropriate  doses.  In 
the  laboratory,  barium  chloride  has  been  found  to  be  a  spe- 
cific for  sensitization  shock  and  in  no  case  has  death  resulted 
after  an  injection  of  solutions  of  proper  strength  from  the 
administration  of  the  protein  poisons.  Its  use  in  human 
beings  has  never  been  investigated,  but  if  its  efifect  should  be 
found  the  same  as  in  the  lower  animals,  it  would  be  a  great 
addition  to  our  list  of  life-saving  drugs. 

The  amount  of  damage  done  to  the  mucosa  may  be  limited 
by  rest  in  bed  and  by  the  avoidance  of  a  diet  which  is  irritating. 
It  will  be  of  the  greatest  advantage  to  our  patient  if  the  heal- 
ing process  has  been  carried  as  far  as  possible  before  allowing 
him  to  return  to  his  regular  duties;  especially  so,  if  the  dis- 
ease does  not  show  signs  of  spontaneous  recovery. 

Drugs  given  to  check  diarrhoea  or  to  produce  bowel  move- 
ments should  be  used  with  extreme  caution.  Cathartics 
retard  the  healing  process  and  through  hastening  the  intestinal 
current  cause  the  chyle  and  feces  in  the  lower  intestine  to 
become  too  rich  in  nutritive  material  and  thus  encourage 
putrefaction. 

The  diet  in  the  primary  stage  must  of  necessity  be  bland 
and  unirritating.  Milk,  preferably  cooked  in  order  that  it 
may  be  sterile  and  its  proteins  slightly  hydrolysed,  makes,  in 
most  cases,  an  ideal  diet.  Gruels  and  broths  may  be  used 
if  the  milk  is  not  well  borne.  Often  scraped  raw  beef  on 
toast  can  be  administered  with  great  benefit  in  the  sacchro- 
butyric,  acetic,  oxalic  and  ammoniacal  types. 

In  the  secondary  stage  a  large  and  varied  armamentarium 
is  an  absolute  necessity  in  the  fight.  The  power  of  the 
various  organisms  with  which  we  will  be  called  upon  to  do 
battle,  to  adjust  themselves  to  new  conditions  and  to  overcome 


78      THE  TREATMENT  OF  ENTEROCOLITIS 

the  effects  of  various  chemicals  which  in  the  beginning  were 
toxic  to  them,  is  well  known.  In  the  same  manner  that  the 
Plasmodium  of  malaria  will  become  quinine  fast,  so  will  the 
intestinal  bacteria  become  salicylate  fast  or  formin  fast. 

Where  mixed  infections  are  present  the  solution  of  the  prob- 
lem presents  even  greater  difficulties.  The  suppression  of 
one  fauna  allows  another  to  gain  the  ascendency,  perhaps  to 
the  detriment  of  the  patient.  This  fact,  however,  at  times 
may  be  turned  to  our  advantage,  always  bearing  in  mind  that 
there  is  not  only  a  substitution  but  also  a  re-substitution  with 
which  to  reckon.  Remedies  often  lose  their  effect  after  a 
few  weeks  and  others  must  be  tried  in  their  place.  Finally, 
either  the  enterocolitis  is  healed,  considerable  improvement 
is  gained  or  the  onset  of  the  tertiary  stage  destroys  all  hope 
of  a  complete  recovery  and  forces  us  to  efforts  to  postpone 
that  fatal  day  when  some  vital  organ  will  cease  to  function- 
ate. 

Indolic  Type. 

Enterocolitis  accompanied  with  the  indolic  type  of  putre- 
faction, in  the  primary  stage  at  least,  usually  heals  with  great 
promptness  under  the  administration  of  hexamethylenamina 
in  small  doses,  combined  with  a  meat  and  toast  diet. 

In  the  secondary  stage  the  therapeutic  course  is  more  pro- 
longed. In  the  milder  conditions,  however,  the  catarrh 
usually  heals  in  a  few  months  under  the  administration  of 
hexamethylenamina,  the  correction  of  starchy  indigestion  and 
a  diet  combining  high  nutritive  value  and  small  weight.  In 
a  few  individuals,  however,  this  course  of  treatment  will  have 
little  effect,  the  indicanuria  will  persist  and  the  catarrh  will 
still  advance.  In  this  case  sodium  salicylate  should  next  be 
tried  and  after  a  week's  treatment  omitted  for  twenty-four 
hours  and  the  urine  tested  for  indican.  Should  the  urine  be 
still  positive  for  indican,  hexamethylenamina  and  sodium 
benzoate  should  next  be  administered  and  test  again  made. 
Meanwhile  the  patient  must  be  carefully  watched  for  any 
signs  of  intestinal  irritation.  If  these  should  appear,  the  use 
of  antiseptic  should  at  once  be  discontinued.  In  some  in- 
dividuals it  will  be  found  impossible  to  establish  a  condition 


THE  TREATMENT  OF  ENTEROCOLITIS  79 

of  asepsis  or  even  partial  asepsis  in  the  intestinal  canal  and 
we  must  be  content  with  the  antiseptic  which  seems  to  agree 
with  the  patient  best  and  continue  its  use  off  and  on,  while 
we  devote  ourselves  to  the  treatment  of  the  catarrh. 

In  the  treatment  of  the  catarrh  the  following  drugs  will  be 
found  of  great  service:  The  wine  of  ipecac  in  small  doses, 
the  tincture  of  belladonna,  bicarbonate  of  soda  and  bromide 
of  soda.  The  ipecac  apparently  increases  the  secretion  of 
the  intestinal  mucosa,  washes  out  the  mucous  glands  and 
turns  the  current  towards  the  lumen  of  the  intestine.  The 
belladonna,  while  checking  secretion  to  a  certain  extent, 
relaxes  the  spasmodic  condition  that  so  often  accompanies 
these  catarrhs  and  relieves  many  disagreeable  symptoms  of 
reflex  nature.  Sodium  bicarbonate  lowers  the  crest  of  the 
acid  wave  originating  in  the  stomach,  helps  out  the  pan- 
creatic juice  in  its  effort  to  sustain  the  alkalinity  of  the  in- 
testinal contents  and  renders  less  irritating  the  organic  acids 
that  the  liver  will  be  called  upon  to  oxidize. 

All  foci  of  suppuration  should  be  removed,  all  bridge  work 
should  be  consigned  to  the  melting  pot,  all  carious  teeth 
extracted  and  any  pyorrhoea  cured  or  failing  in  this  the  teeth 
removed  and  a  plate  fitted. 

Fingers  should  be  kept  out  of  the  mouth  and  nose  and  the 
teeth  should  be  thoroughly  cleaned  at  least  twice  daily. 

The  need  of  antiseptics  will  be  much  lessened  if  the  food 
is  as  sterile  as  possible.  This  condition  can  be  obtained 
through  care  in  handling  raw  foodstuffs  and  especially,  in  the 
case  of  vegetables,  by  the  most  thorough  cooking.  Until 
the  succus  entericus  has  regained  its  bacteriolytic  activity 
all  uncooked  foods  or  foods  that  have  stood  some  time  after 
cooking,   should   be   prohibited. 

In  the  secondary  stage  very  little  headway  can  be  made  in 
the  cure  of  enterocolitis  while  excessive  putrefactive  pro- 
cesses are  going  on  in  the  intestinal  canal.  The  best  plan  is 
first  to  give  the  patient  a  course  of  intestinal  antiseptics  and 
to  delay  therapeutic  measures  directed  to  the  cure  of  the 
catarrh  until  the  indices  of  intestinal  putrefaction  are  no 
longer  present  in  the  urine. 


80      THE  TREATMENT  OF  ENTEROCOLITIS 

The  name  of  antiseptic  drugs  is  legion  and  a  list  of  them 
can  easily  be  compiled  from  any  text-book  on  therapeutics. 
It  will  be  found,  however,  that  the  best  place  to  begin  the 
sterilizing  process  is  at  the  vermilion  border  of  the  lips.  In 
some  instances  the  outposts  may  be  pushed  as  far  as  the  gar- 
den, the  market,  the  ice  box,  kitchen  and  eating  utensils, 
with  what  may  seem  favorable  results.  In  the  fight  for  asep- 
sis the  nose  and  its  sinuses,  the  posterior  nares,  the  tonsils 
and  the  teeth  must  not  be  forgotten  and  these  matters  had 
best  be  taken  in  hand  by  men  who  have  a  correct  understand- 
ing of  the  task  at  hand. 

Saccharobutyric  Type. 

This  can  best  be  treated  by  means  of  the  salicylate  of  soda 
given  in  small  doses  as  this  drug  is  almost  specific  in  its  action. 
Like  all  other  intestinal  antiseptics,  however,  its  long  con- 
tinued administration  does  not  give  good  results.  Its  first 
effect  will  be  to  diminish  greatly  the  volume  of  fecal  matter 
discharged  per  diem,  and  as  this  is  generally  regarded  as  an 
alarming  condition  by  the  patient,  he  had  better  be  prepared 
beforehand  for  this  result.  The  first  course  had  better  last 
one  week  and  never  longer  than  two  weeks,  for  if  longer  con- 
tinued certain  butyric  acid  producers  tend  to  become  sali- 
cylate fast. 

As  the  first  symptoms  of  this  type  arise  from  the  fact  that 
the  liver  is  becoming  insufficient  for  the  task  imposed  upon  it, 
and  as  this  is  caused  primarily  by  the  excess  of  butyric 
acid,  either  free  or  in  loose  combination,  in  the  portal  circu- 
lation, it  is  well  to  administer  the  alkaline  carbonates  well 
diluted  with  water.  The  liver  seems  to  be  better  able  to 
handle  these  acids  if  they  are  combined  with  sodium  or  potas- 
sium. This  fact  is  shown  clinically  by  a  decrease  in  the  sen- 
sitiveness of  the  right  hypochondrium  and  a  reduction  in 
the  size  of  the  liver.  Alkaline  mineral  waters  usually  have 
some  cathartic  action,  therefore  their  general  use  is  not  to  be 
recommended. 

It  must  not  be  forgotten,  however,  that  our  greatest  efforts 
should  be  directed  to  the  healing  of  the  enterocolitis,  the 


THE  TREATMENT  OF  ENTEROCOLITIS      81 

ravages  of  which  allow  the  growth  of  butyric  acid-producing 
bacteria  to  proceed  unchecked  in  the  patient's  intestinal 
canal.  Drugs,  such  as  ipecac,  belladonna,  hydrastis,  that 
enjoy  a  reputation  in  the  treatment  of  the  catarrh  may  be 
prescribed,  but  little  can  be  accomplished  through  their  use 
if  the  patient  persists  in  following  a  diet  which  favors  the 
growth  of  those  bacteria  that  are  always  present  in  this  type 
of  putrefaction. 

Diet  alone  will  always  benefit  this  catarrh  in  the  secondary 
stage  and  many  of  the  milder  cases  can  be  cured  by  this  means 
alone.  For  the  first  few  weeks  that  the  patient  is  under  treat- 
ment, the  diet  should  be  that  ordinarily  given  in  diabetes  with 
strict  orders  to  omit  all  uncooked  vegetables.  If  there  is  a 
ptosis  or  a  tendency  to  ptosis  of  the  viscera,  solids  and  liquids 
should  not  be  allowed  to  be  taken  within  two  hours  of  each 
other.  Milk  is  not  well  borne  by  these  patients  and  should 
always  be  forbidden. 

The  micro-organisms  of  this  type  are  very  generally  strict 
or  facultative  anaerobes,  very  difficult  to  cultivate  in  the  lab- 
oratory without  special  apparatus.  The  patient,  moreover, 
spends  the  whole  of  his  life  in  an  atmosphere  of  oxygen  of 
just  the  right  dilution  for  therapeutic  use.  The  use  of  ene- 
meta  of  atmospheric  air  often  produces  marvelous  results  in 
these  sufferers,  more  especially  if  diarrhoea  is  present.  This 
may  best  be  administered  with  a  bulb  syringe,  the  average 
amount  introduced  being  six  ounces.  Two  bulbsful  usually 
make  this  amount  in  the  ordinary  Davidson  syringe.  A 
special  hydro-pneumatic  apparatus  designed  for  this  pro- 
cedure was  found  to  have  no  special  advantages  over  the 
syringe  mentioned  above. 

Enemeta  of  water,  decinormal  salt  solution,  antiseptics  and 
astringents  uniformly  seem  to  do  more  harm  than  good. 

Abdominal  massage,  electricity  and  hydrotherapy  have 
been  found  of  little  use. 

The  correction  of  ptoses  by  strapping  has  been  of 
great  service  where  such  procedures  are  indicated.  Experi- 
ence teaches  that  the  simpler  the  apparatus  can  be  made 
the  better.     After  trying  the  various  nicely  patterned  belts 


82      THE  TREATMENT  OF  ENTEROCOLITIS 

that  have  been  invented,  finally  one  constructed  of  a  strip 
of  zinc  oxid  plaster  3i  inches  wide,  applied  across  the  small 
of  the  back,  brought  forward  just  about  the  crests  of  ilium, 
crossed  midway  between  the  umbilicus  and  the  pubes  and 
secured  with  a  pin,  was  given  the  preference.  The  point  of 
this  pin  is  cut  ofif  and  a  small  piece  of  plaster  applied  to  pre- 
vent  injury   to   the   clothing. 

As  the  patient  progresses  toward  recovery  first  one  vege- 
table and  then  another  is  restored  to  the  diet  and  the  effect 
carefully  noted.  Finally  most  patients  can  be  allowed  a 
regular  table  diet.  On  the  other  hand,  many  individuals 
will  be  encountered  who  are  unable  and  always  will  be  un- 
able to  indulge  in  salads  or  other  uncooked  vegetables. 

The  Acetic  Type. 

The  acetic  type  of  intestinal  putrefaction  in  the  secondary 
stage  can  best  be  handled  through  the  diet  and  many  will 
recover  promptly  through  this  means  alone. 

The  individuals  who  have  an  acetonuria  alone,  may  not 
consider  themselves  as  departing  very  far  from  a  normal 
condition,  but  when  the  urine  shows  repeatedly  a  reaction  for 
this  chemical  there  are  sure  to  be  stormy  days  ahead.  Slightly 
limiting  the  amount  of  starchy  foods,  the  administration 
of  a  mild  intestinal  antiseptic,  such  as  sodium  salicylate  or 
hexamethylenamina  for  a  few  days  usually  corrects  the  trouble. 

When  diacetic  acid,  oxybutyric  acid  or  the  acetic  deriva- 
tives are  present,  the  therapeutic  problem  is  one  of  greater 
difficulty.  The  so-called  antidiabetic  diet  will  be  found  of 
great  usefulness  as  a  means  of  treatment.  There  is  one 
exception,  however,  that  must  be  carefully  enforced  and  this 
is  the  total  abstinence  from  all  raw  foods,  or  from  any  food 
that  has  been  allowed  to  stand  long  after  cooking,  such  as 
cold  meats,  cold  vegetables,  vegetable  salads  and  foods  of 
like  nature.  In  the  severe  grades  of  putrefaction  even  the 
drinking  water  should  be  first  boiled  before  using  and  the 
danger  of  infectious  contact  should  also  be  guarded  against. 

The  intestinal  antiseptics  mentioned  before  may  be  tried  in 


THE  TREATMENT  OF  ENTEROCOLITIS      83 

turn.  There  appears  to  be  no  fixed  rule  governing  the  ad- 
ministration of  the  class  of  remedies.  In  some,  the  salicyl- 
ates may  be  used  to  great  advantage;  in  others,  hexamethyl- 
enamina  either  alone  or  in  combination  with  sodium  ben- 
zoate  will  cause  the  urine  to  become  negative;  while  in  others, 
Fowler's  solution  or  potassium  iodide  will  accomplish  the 
desired  results. 

The  intestinal  catarrh  should  be  attacked  after  the  indices 
of  putrefaction  have  either  been  brought  to  zero  or  very 
materially  lessened  in  strength.  Ipecac,  belladonna,  bis- 
muth subnitrate  or  subgallate,  dilute  nitric  acid,  the  alkaline 
carbonates  may  be  tried  and  the  ones  that  seem  the  most 
useful  in  this  special  case  administered. 

As  in  the  other  forms  of  putrefaction,  cathartics  are  to  be 
avoided  as  much  as  possible,  in  order  that  the  contents  of  the 
lower  portion  of  the  intestinal  canal  may  be  as  deficient  in 
nutritive  material  as  possible.  If  the  patient  seems  to  be 
worse  when  constipated  castor  oil,  aloin,  cascara  sagrada, 
may  be  tried  with  or  without  podophylin.  The  rule  is,  how- 
ever, unless  the  patient  shows  dangerous  symptoms  or  the 
disease  has  progressed  so  far  as  to  be  well-nigh  hopeless,  to 
fight  it  out  with  the  aid  of  enemeta  and  lubricants. 

As  in  the  saccharobutyric  type,  enemeta  of  atmospheric 
air,  especially  if  diarrhoea  is  present  as  a  complication,  are 
often  of  great  service. 

Massage,  electricity,  hydrotherapy  and  lavage  are  of  very 
little  benefit.  A  change  of  scene  and  climate  is  of  service 
as  it  often  removes  the  patient  from  a  source  of  infection  that 
impedes  his  recovery. 

The  treatment  of  the  tertiary  stage  is  a  task  for  the  well 
trained  internist.  The  means  taken  to  gain  time  for  the 
patient,  of  course,  varies  with  the  organ  or  organs  that  have 
been  affected  through  the  attack  of  the  disease.  The  prin- 
ciples of  treatment  laid  down  above  will  be  found  of  great  use 
in  combination  with  those  set  forth  in  treatises  upon  dis- 
eases of  the  pancreas,  liver,  heart,  blood  vessels,  nervous 
system  and  other  organs  of  special  function. 


84  THE  TREATMENT  OF  ENTEROCOLITIS 

Oleic  Type. 

In  the  primary  stage  of  oleic  putrefaction,  the  patients 
are  generally  very  ill.  In  consequence,  these  patients  had 
better  be  kept  in  bed  until  recovery  is  well  advanced. 

Castor  oil  in  small  doses  frequently  repeated  is  well-nigh  a 
specific  in  this  type  of  putrefaction.  It  should  be  given  in 
half  dram  doses,  once  in  two  hours.  It  may  seem  paradoxi- 
cal that  a  type  of  putrefaction  where  the  invading  micro- 
organism attacks  oils  with  vigor  should  be  improved  by  the 
administering  of  another  oil.  Castor  oil  seems  to  contain, 
some  chemical  body  which  is  antiseptic  in  its  action.  It  is 
well  known  that  oleum  ricini  very  seldom  becomes  rancid, 
while  the  other  edible  oils  spoil  in  the  course  of  a  few  days. 
Other  intestinal  antiseptics  may  be  of  value  if  the  castor  oil 
is  poorly  borne  by  the  stomach.  Hexamethylenamina  either 
alone  or  in  combination  with  sodium  benzoate  is  an  efficient 
remedy.  This  may  be  alternated  with  sodium  salicylate, 
if  the  duration  of  the  primary  stage  is  longer  than  one  week. 

The  diet  should  be  absolutely  fat  free.  This  excludes 
milk,  cream,  butter,  the  fat  of  meat  and  oils  of  all  kinds. 
Broths,  when  free  of  fat,  may  be  allowed,  soups  thickened 
with  cornstarch,  arrowroot  or  flour,  dry  toast,  finely  divided 
meat,  cooked  or  raw  or  skimmed  milk. 

In  the  secondary  stage,  the  above  named  antiseptics  may  be 
used  alternately.  In  addition  to  these,  the  preparations  of  ar- 
senic, especially  Fowler's  solution  in  small  doses  will  be  found  of 
benefit.     Occasionally  potassium  Iodide  will  prove  beneficial. 

The  abstinence  from  fats  and  oils  must  be  kept  up  for 
several  months  after  improvement  has  taken  place. 

In  the  tertiary  stage  little  can  be  done.  The  patient  usually 
needs  constant  care,  either  from  an  attendant  or  in  some 
institution. 

In  the  treatment  of  enterocolitis  constipation  is  a  very 
troublesome  symptom.  So  strongly  has  the  importance  of 
free  evacuations  of  the  bowels,  and  the  so-called  constipa- 
tion high  up  and  its  deleterious  influences  upon  health  and 
life,  been  impressed  upon  the  minds  of  the  patrons  of  the 
medical  profession,  that  were  this  doctrine  true  and  appli- 


THE  TREATMENT  OF  ENTEROCOLITIS      85 

cable  to  all  members  of  the  animal  kingdom  who  possess  in- 
ternal digestive  systems,  the  surface  of  the  earth  would  be 
left  as  an  habitat  for  protozoa,  bacteria,  molds,  yeasts  and 
other  organisms,  who  gain  nutrition  through  their  external 
surfaces,  and  to  no  others. 

Fortunately,  constipation  is  not  such  a  fatal  disease  as  we 
have  been  led  to  believe.  It  is  a  difhcult  matter  to  decide 
what  is  the  normal  habit  of  defecation  for  various  individuals. 
Some  people  have  normally  two  stools  a  day,  others,  and  in 
truth  they  may  be  in  the  majority,  have  one  per  diem.  Many 
others,  strange  as  it  may  seem,  get  along  extremely  well  with 
one  or  two  a  week  until  convinced  by  some  friend  that  they 
would  be  in  better  health  if  their  stools  were  more  copious  and 
frequent  and  take  measures  to  accomplish  this  result.  In  such 
cases,  trouble  is  not  long  in  developing.  Many  instances 
have  been  reported  in  which  the  normal  habit  was  as  infre- 
quent as  once  a  month  without  serious  consequences,  so  far 
as  bodily  health  and  comfort  were  concerned.  When  a 
marked  putrefaction  is  present  in  the  intestinal  contents, 
constipation  may  become  a  disagreeable,  if  not  a  dangerous 
symptom.  He  who  attempts  to  cure  sufferers  from  entero- 
colitis through  the  use  of  cathartics,  however,  will  find  that 
the  results  of  treatment  will  be  uniformly  unsatisfactory. 

In  connection  with  the  subject  of  constipation,  it  is  found 
that  the  contents  of  the  colon  are  not,  in  health,  very  rich  in 
nutritive  materials.  The  colon  may  be  regarded  as  the 
reclamation  plant  of  the  gastrointestinal  canal.  Within  its 
cavity,  the  greater  part  of  the  water,  mucus,  enzymes  and 
hormones  are  recovered  and  turned  back  again  into  the  blood 
and  lymph  streams  for  future  use  in  the  digestive  process. 

When  through  catharsis,  the  contents  of  the  small  intes- 
tine have  been  moved  forward  into  the  colon  before  the  absorp- 
tion of  proteids,  carbohydrates  and  fats  has  advanced  to  a 
proper  degree,  putrefaction  is  greatly  favored.  If  this  con- 
dition is  present  day  after  day,  in  a  greater  or  less  length  of 
time,  through  an  overabundance  of  nutritive  material  favor- 
ing the  growth  of  putrefactive  bacteria,  a  catarrhal  condi- 
tion will  most  certainly  be  established. 


86      THE  TREATMENT  OF  ENTEROCOLITIS 

The  stools  in  enterocolitis  often,  under  analysis,  show  a 
bacterial  content,  living,  dead  and  autolysed,  of  ninety-nine 
per  cent,  according  to  the  investigations  of  Strasburger  and 
Herter.  Consequently  it  may  be  assumed  that  the  more 
copious  the  stools,  the  greater  the  putrefaction.  Therefore, 
a  patient  who  is  passing  one  pound  of  fecal  matter  a  day  is 
losing  0.99  of  a  pound  of  nutrition,  plus  the  amount  of  carbon, 
hydrogen  and  nitrogen  that  is  wasted  as  gaseous  bodies  in 
bacterial  metabolism. 

The  intestinal  condition  in  constipation  may  be  expressed 
by  the  following  equation: 

(1)  0+C  +  I  +  T. 

In  which  O  may  represent  obstipation;  C,  a  catarrhal  pro- 
cess; I,  an  infection  with  the  bacteria  of  putrefaction,  and  T, 
the  toxemia  arising  therefrom. 

It  is  easy  to  see  that  in  the  presence  of  certain  very  toxic 
members  of  the  families  Bacterium  and  Hyphomycetis,  this 
condition  may  be  dangerous  to  the  patient's  welfare  and  more 
especially  to  the  integrity  of  some  of  the  more  delicate  organs 
of  metabolism  and  excretion.  It  is  difficult  to  see,  however, 
how  any  great  harm  could  be  done  if  the  intestinal  conditions 
were  so  simplified  that  the  equation  would  read  as  follows: 

(2)  0  +  C. 

Or,  bearing  in  mind  the  fact  that  the  mass  of  the  stool 
varies  with  the  bacterial  activity,  what  damage  could  possibly 
come  to  the  general  parenchyma  of  our  patient,  even  if  he 
should  have  but  one  stool  a  week,  if  his  intestinal  condition 
could  be  represented  by 

(3)  O. 

As  a  corollary,  O  may  be  replaced  by  D,  representing 
diarrhoea,  in  equations  1,  2  and  3.  In  this  case  we  have  the 
condition  present  in  many  of  our  patients,  who  have  con- 
tracted intestinal  diseases  in  tropical  climates  and  to  whom 
the  intestinal  equation  0  +  C  +  I  +  T  would  give  a  marked 
degree  of  comfort,  as  well  as,  in  comparison,  the  greatest 
satisfaction. 


THE  TREATMENT  OF  ENTEROCOLITIS      87 

The  use  of  cathartic  medicines  is  not  to  be  recommended 
and  their  long-continued  administration  will  make  all  chronic 
conditions  much  worse.  Even  in  conditions  of  intestinal 
atony  without  catarrh  the  administration  of  such  drugs  will 
eventually  cause  a  colitis  or  an  enterocolitis  to  develop. 

Under  the  teaching  of  Lane,  highly  purified  mineral  oils  have 
come  much  into  vogue  for  the  relief  of  constipation.  The 
study  of  feces  during  such  treatment,  however,  leads  to  the 
belief  that  these  oils  cause  an  increase  of  putrefaction  in  the 
intestines. 

The  various  vegetable  gums  were  also  tested  as  intestinal 
lubricants.  Agar  agar  gave  fair  results.  Finely  ground 
sea  moss  of  the  variety  chondrus  crispus,  however,  seems  to 
be  the  best.  It  has  the  advantage  of  being  a  native  product 
of  low  cost,  is  very  well  borne  by  the  stomach,  is  soothing  to 
the  intestinal  mucosa,  produces  large  well  formed  stools  and 
seems  to  check  rather  than  encourage  putrefaction. 


CHAPTER  XV 

GENERAL  CONSIDERATION  OF 
ENTEROCOLITIS 


Many  of  the  statements  made  in  the  Hterature  of  entero- 
colitis do  not  bear  the  test  of  laboratory  investigation.  The 
two  most  commonly  reiterated  doctrines,  the  importance  of 
overeating  as  a  causative  factor  and  the  bad  effect  of  con- 
suming certain  common  articles  of  food  in  abundance,  have 
been  proven  to  be  without  foundation.  There  are,  of  course, 
a  great  many  sufferers  from  this  disease  who  habitually  over- 
eat and  who  have  done  so  all  their  lives,  but  the  fact  that 
they  have  contracted  a  chronic  catarrh  of  the  intestinal  tract 
must  be  accounted  for  on  other  grounds  than  an  overindul- 
gence in  the  pleasures  of  the  table.  In  the  majority  of  patients 
conditions  bordering  on  starvation  are  more  generally  found. 

Through  the  teaching  of  our  friends,  the  vegetarians,  the 
opinion  has  become  very  general,  that  animal  foods  have  a 
certain  poisonous  effect  upon  both  mind  and  body,  that  their 
use  leads  to  early  decay  of  the  blood  vessels  and  that  their  con- 
sumption at  best  is  but  a  relic  of  barbarism.  People  are  all 
the  more  ready  to  accept  this  belief,  as  the  price  of  meat 
products  has  risen  to  an  alarming  extent  in  the  past  twenty 
years  and  the  cost  of  living  may  be  materially  reduced  by 
following  a  meat-free  diet.  Moreover,  cheating  the  stomach 
seems  to  be  a  very  popular  pastime  among  a  certain  class  of 
people  and  routines  directed  to  the  relief  of  abdominal  symp- 
toms through  starvation  treatment  are  coming  more  and  more 
into  vogue. 

Another  great  cause  of  intestinal  damage  is  the  very  prev- 
alent use  of  foods  that  have  been  cooked  several  weeks  or 
months  previous  to  consumption.  This  applies  not  only  to 
meats  and  vegetables,  but  to  cereals  as  well.     This  condition 


GENERAL  CONSIDERATION  89 

may  be  accounted  for  partly  by  the  well  ordered  advertising 
campaigns  conducted  through  the  columns  of  the  press  by 
enterprising  manufacturers  of  such  products,  but  in  a  greater 
degree  through  the  innate  laziness  of  the  average  American 
cook  and  the  widespread  ignorance  of  the  art  of  good  cooking. 
We  are  rapidly  becoming  a  tin  can  and  carton  race,  so  far  as 
our  food  supply  is  concerned.  Even  in  the  rural  districts, 
the  tin  can  has  become  ubiquitous  and  the  number  of  empty 
ones  found  on  the  premises  may  be  said  to  vary  inversely 
with  the  thrift  of  the  family.  Truly  it  is  shameful  to  find  tin 
cans  labeled  "pork  and  beans"  upon  the  premises  of  any  self- 
respecting  farmer.  On  the  other  hand,  in  the  best  hotels  in 
the  land  the  use  of  canned  vegetables  is,  if  not  extremely 
common,  the  rule.  If  a  vegetable  served  on  these  tables  is 
fresh,  even  when  common  in  the  markets  at  the  time,  the  fact 
is  remarked  upon  and  used  as  an  excuse  for  an  advance  in 
price.  One  often  wonders  what  may  be  the  age  of  the  canned 
goods  served  in  the  average  restaurant. 

Meat  is  often  a  cause  of  trouble.  Some  of  it  served  in 
public  eating  houses,  through  age  or  maltreatment,  is  irri- 
tating to  the  intestinal  mucosa,  to  say  the  least.  The  methods 
of  the  storage  of  meat,  poultry  and  eggs  is  often  open  to 
criticism.  Meat  that  requires  the  liberal  use  of  highly  aro- 
matic condiments  to  disguise  the  odor  and  taste  of  advancing 
putrefaction  is  well  known  to  be  dangerous,  yet  it  is  served 
every  day  in  every  city. 

Another  cause  for  remark  is  the  filthy  condition  that  exists 
in  the  ice  boxes,  kitchens  and  serving  room,  and  the  unclean- 
liness  of  the  personnel,  not  only  in  public  eating  houses  but  in 
many  homes  as  well.  It  may  seem  an  exaggeration  to  state 
that  the  cook  who  prepares  our  food,  the  waiter  who  serves 
it  in  so  polished  a  manner,  or  the  scullion  who  cleans  the 
eating  utensils,  may  communicate  sickness,  but  when  one 
bears  in  mind  the  great  prevalence  of  fecal  matter  upon  the 
hands  and  person  of  the  average  individual,  the  subject 
takes  a  different  aspect.  It  must  not  be  forgotten  that  the 
chef  may  have  an  intestinal  fauna  to  which  he  is  immune, 
but  which  on  the  other  hand  may  lead  to  a  premature  death 


90  GENERAL  CONSIDERATION 

or  at  least  months  or  years  of  incapacity  to  one  of  the  guests 
he  might  inadvertently  infect. 

New  strains  of  micro-organisms,  introduced  through  the 
agency  of  immigration  and  travel,  no  doubt  are  beginning  to 
have  a  marked  influence  upon  the  intestinal  condition  of  our 
native  population.  The  intestinal  fauna  in  some  of  our 
patients  who  have  lived  in  the  Orient  is  often  remarkable  and 
the  effect  that  the  bacteria  that  these  people  harbor  without 
inconvenience  may  have  upon  the  health  and  vitality  of  the 
American  born,  furnishes  a  very  interesting  problem  and  one 
deserving  of  careful  study.  Possibly,  the  great  decrease  in 
the  fecundity  of  our  population  may  be  ascribed  to  various 
chronic  infections  against  the  attack  of  which  the  individual 
has  not  acquired  an  immunity.  It  is  a  fact  that  a  conquest 
is  going  on  through  the  agency  of  intestinal  putrefactions  and 
of  plasmodiasis,  instead  of  by  force  and  arms,  that  will  even- 
tually change  the  character  of  the  race. 

The  change  from  country  to  urban  life,  the  lack  of  fresh 
air  and  sunshine,  the  intimate  contact  with  sources  of  infec- 
tion that  a  city  life  necessitates,  the  competitions,  worries 
and  anxieties  of  modern  life,  all  must  have  their  effect. 

The  connection  between  this  catarrh  and  other  general 
chronic  infections  such  as  tuberculosis  and  malaria  is  very 
intimate.  So  important  is  this  fact  that  tubercular  and 
malarial  infections  may  be  said  to  be  the  most  common  com- 
plications of  the  secondary  stage  of  enterocolitis. 

The  financial  and  political  loss  to  the  nation  resulting  from 
intestinal  infections  presents  one  of  the  most  serious  prob- 
lems of  enterocolitis.  Through  its  attack  the  length  of  life 
and  efficiency  of  its  victims  are  reduced  about  twenty-five 
per  cent.  It  is  a  greater  and  more  far-reaching  problem  than 
the  hook  worm  disease  or  tuberculosis  presents  today. 

Sufferers  from  enterocolitis  fall  an  easy  prey  to  habit-form- 
ing drugs.  Especially  liable  are  they  to  use  habitually  the 
insidious  coal  tar  series  or  the  proprietary  articles  that  con- 
tain them.  Morphine  claims  a  good  many  victims,  and,  on 
account  of  the  depression  of  sexual  desire  that  accompanies 
many  types  of  putrefaction,  the  aphrodisiac  effect  of  cocaine 


OF  ENTEROCOLITIS  91 

is  often  sought.  The  persistence  of  an  acetanilid  habit  is 
not  generally  realized.  It  is  so  easily  obtained  in  the  open 
market,  its  use  causes  so  little  comment,  so  many  supposedly 
innocuous  proprietary  compounds  contain  it  in  large  pro- 
portion, that  once  formed  the  habit  is  hard  to  break.  A 
vast  number  of  popular  beverages  and  nostrums  depending 
upon  caffeine  for  their  stimulating  effect  are  also  very  popular 
with  these  patients  and  these  combined  with  the  ubiquitous 
cocktail  and  other  alcoholic  cordials  and  tipples  add  their 
quota  to  the  damage  day  by  day. 

The  average  American  is  to-day  not  only  underfed  but  also 
underclothed.  The  thinness  of  clothing  has  become  a  popu- 
lar fad.  As  a  result  the  resistance  of  the  body  is  impaired 
by  overheated  homes  and  offices. 

The  prevention  of  this  disease  presents  a  problem  in- 
timately connected  with  the  prolongation  of  human  life. 
The  return  to  a  simpler  life,  with  lessened  worry  and  anxiety; 
less  time  and  money  spent  in  the  pursuit  of  pleasures,  that 
must  be  taken  in  the  end  from  the  family  food  and  clothing; 
plainer  and  better  food,  better  cooked;  a  more  evenly  bal- 
anced diet;  the  abstinence  from  irritating  foods  and  condi- 
ments; the  avoidance  of  habitual  catharsis;  and  finally  more 
fresh  air  and  sunshine;  all  suggest  themselves  as  measures 
that  may  well  be  used  in  the  prevention  of  enterocolitis. 


